Provider Demographics
NPI:1073887642
Name:DR. ANDREA T. GORDON DDS,LLC
Entity Type:Organization
Organization Name:DR. ANDREA T. GORDON DDS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:T
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-361-6767
Mailing Address - Street 1:1408 N KINGSHIGHWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63113-1400
Mailing Address - Country:US
Mailing Address - Phone:314-361-6767
Mailing Address - Fax:314-361-1480
Practice Address - Street 1:1408 N KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-1400
Practice Address - Country:US
Practice Address - Phone:314-361-6767
Practice Address - Fax:314-361-1480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0136891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO401900311Medicaid
MO979390OtherUNITED CONCORDIA
MO3051OtherDENTAQUEST