Provider Demographics
NPI:1124199468
Name:GORDON, JOE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOE
Middle Name:
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 1:514 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1989
Mailing Address - Country:US
Mailing Address - Phone:847-482-1900
Mailing Address - Fax:847-482-1909
Practice Address - Street 1:514 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1989
Practice Address - Country:US
Practice Address - Phone:847-482-1900
Practice Address - Fax:847-482-1909
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry