Provider Demographics
NPI:1114070349
Name:GORDON, PETER G (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:G
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 1:23300 CHAGRIN BLVD
Mailing Address - Street 2:G-10
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5557
Mailing Address - Country:US
Mailing Address - Phone:216-464-1180
Mailing Address - Fax:216-464-3707
Practice Address - Street 1:23300 CHAGRIN BLVD
Practice Address - Street 2:G-10
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5557
Practice Address - Country:US
Practice Address - Phone:216-464-1180
Practice Address - Fax:216-464-3707
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH126791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice