Provider Demographics
NPI:1073625026
Name:GORDON, DENNIS (RD)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 ELLIOTT DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1032
Mailing Address - Country:US
Mailing Address - Phone:734-712-1049
Mailing Address - Fax:
Practice Address - Street 1:5320 ELLIOTT DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1032
Practice Address - Country:US
Practice Address - Phone:734-712-1049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP 16870002Medicare UPIN