Provider Demographics
NPI:1164636528
Name:GORDON, ERIC LAWRENCE (DDS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:LAWRENCE
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 1:7441 W RIDGEWOOD DR
Mailing Address - Street 2:SUITE 275
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129
Mailing Address - Country:US
Mailing Address - Phone:440-842-0909
Mailing Address - Fax:440-842-0910
Practice Address - Street 1:7441 W RIDGEWOOD DR
Practice Address - Street 2:SUITE 275
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129
Practice Address - Country:US
Practice Address - Phone:440-842-0909
Practice Address - Fax:440-842-0910
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300145381223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0408786Medicaid