Provider Demographics
NPI:1528096765
Name:DAVIS, GORDON H (DMD,DMSC)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:H
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DMD,DMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4161 ROUTE 22
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-5883
Mailing Address - Country:US
Mailing Address - Phone:518-563-0040
Mailing Address - Fax:518-562-0632
Practice Address - Street 1:4161 ROUTE 22
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-5883
Practice Address - Country:US
Practice Address - Phone:518-563-0040
Practice Address - Fax:518-562-0632
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047679-11223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics