Provider Demographics
NPI:1386121366
Name:GORDON, STEPHANIE (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1385 SANDERS LN
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-7435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2854 NORTHWESTERN PIKE
Practice Address - Street 2:
Practice Address - City:CAPON BRIDGE
Practice Address - State:WV
Practice Address - Zip Code:26711-9052
Practice Address - Country:US
Practice Address - Phone:304-856-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4498122300000X
MD165781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice