Provider Demographics
NPI:1043364599
Name:GORDON, DIANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIANN
Middle Name:
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:PO BOX 665
Mailing Address - Street 2:
Mailing Address - City:HAYES
Mailing Address - State:VA
Mailing Address - Zip Code:23072-0665
Mailing Address - Country:US
Mailing Address - Phone:804-642-2212
Mailing Address - Fax:804-642-9026
Practice Address - Street 1:3224 GEORGE WASHINGTON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:HAYES
Practice Address - State:VA
Practice Address - Zip Code:23072-3312
Practice Address - Country:US
Practice Address - Phone:804-642-2212
Practice Address - Fax:804-642-9026
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010082841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice