Provider Demographics
NPI:1073593497
Name:GORDON, LEO DAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:DAN
Last Name:GORDON
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 1:503 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEIMAR
Mailing Address - State:TX
Mailing Address - Zip Code:78962
Mailing Address - Country:US
Mailing Address - Phone:979-725-8562
Mailing Address - Fax:979-725-6822
Practice Address - Street 1:503 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WEIMAR
Practice Address - State:TX
Practice Address - Zip Code:78962
Practice Address - Country:US
Practice Address - Phone:979-725-8562
Practice Address - Fax:979-725-6822
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX156211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
D15621OtherBCBS
837109OtherUNITED CONCORDIA
837109OtherUNITED CONCORDIA