Provider Demographics
NPI:1316997240
Name:GORDON, RYAN LEE (DDS MS)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:LEE
Last Name:GORDON
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 23029
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423
Mailing Address - Country:US
Mailing Address - Phone:612-861-9123
Mailing Address - Fax:612-861-9155
Practice Address - Street 1:6601 LYNDALE AVE S
Practice Address - Street 2:SUITE 230 WOODLAKE CENTRE
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423
Practice Address - Country:US
Practice Address - Phone:612-638-1224
Practice Address - Fax:612-638-1232
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MND116201223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics