Provider Demographics
NPI:1699877464
Name:GORDON, JENNIFER L (DDS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
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 1:1181 CENTRAL BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-2252
Mailing Address - Country:US
Mailing Address - Phone:925-634-6105
Mailing Address - Fax:925-634-7372
Practice Address - Street 1:1181 CENTRAL BLVD STE E
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-2252
Practice Address - Country:US
Practice Address - Phone:925-634-6105
Practice Address - Fax:925-634-7372
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA416081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice