Provider Demographics
NPI:1891957874
Name:DAMMANN, GORDON EDWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:EDWARD
Last Name:DAMMANN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 W RAILROAD ST
Mailing Address - Street 2:POBOX 516
Mailing Address - City:LENA
Mailing Address - State:IL
Mailing Address - Zip Code:61048-9038
Mailing Address - Country:US
Mailing Address - Phone:815-369-2611
Mailing Address - Fax:815-369-2720
Practice Address - Street 1:123 W RAILROAD ST
Practice Address - Street 2:
Practice Address - City:LENA
Practice Address - State:IL
Practice Address - Zip Code:61048-9038
Practice Address - Country:US
Practice Address - Phone:815-369-2611
Practice Address - Fax:815-369-2720
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-0135841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice