Provider Demographics
NPI:1043695513
Name:AVERILL, GORDON (DMD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:AVERILL
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 1:2435 PLANTATION CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5148
Mailing Address - Country:US
Mailing Address - Phone:704-847-7426
Mailing Address - Fax:
Practice Address - Street 1:2435 PLANTATION CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5148
Practice Address - Country:US
Practice Address - Phone:704-847-7426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS101899122300000X
NC12810122300000X
MADN1856859122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1043695513Medicaid