Provider Demographics
NPI:1023045747
Name:BULLOCK, GORDON K (DMD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:K
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:582 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97448-1271
Mailing Address - Country:US
Mailing Address - Phone:541-998-8147
Mailing Address - Fax:541-998-3568
Practice Address - Street 1:582 LAUREL ST
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:OR
Practice Address - Zip Code:97448-1271
Practice Address - Country:US
Practice Address - Phone:541-998-8147
Practice Address - Fax:541-998-3568
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR48131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice