Provider Demographics
NPI:1164957635
Name:DR MICHAEL J GORDON DDS PA
Entity Type:Organization
Organization Name:DR MICHAEL J GORDON DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:828-459-1400
Mailing Address - Street 1:311 NC HIGHWAY 16 S
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28681-3050
Mailing Address - Country:US
Mailing Address - Phone:704-277-2531
Mailing Address - Fax:
Practice Address - Street 1:311 NC HIGHWAY 16 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28681-3050
Practice Address - Country:US
Practice Address - Phone:704-277-2531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9539122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty