Provider Demographics
NPI:1083715486
Name:GORDON, BRENDA JO (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:JO
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 1:141 W JACKSON BLVD
Mailing Address - Street 2:#3632
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-2929
Mailing Address - Country:US
Mailing Address - Phone:312-939-2400
Mailing Address - Fax:
Practice Address - Street 1:141 W JACKSON BLVD
Practice Address - Street 2:#3632
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-2929
Practice Address - Country:US
Practice Address - Phone:312-939-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300189041223G0001X
CA324271223G0001X
IL0190203381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice