Provider Demographics
NPI:1992948780
Name:PATRICIA D GORDON
Entity type:Organization
Organization Name:PATRICIA D GORDON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:888-556-0225
Mailing Address - Street 1:21001 COVELLO STREET
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303
Mailing Address - Country:US
Mailing Address - Phone:888-556-0225
Mailing Address - Fax:323-443-3904
Practice Address - Street 1:21001 COVELLO STREET
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303
Practice Address - Country:US
Practice Address - Phone:888-556-0225
Practice Address - Fax:323-443-3904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54899122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty