Provider Demographics
NPI:1184028391
Name:GORDON, MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3706 N ROOSEVELT BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-4566
Mailing Address - Country:US
Mailing Address - Phone:305-332-4168
Mailing Address - Fax:305-735-4041
Practice Address - Street 1:3706 N ROOSEVELT BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-4566
Practice Address - Country:US
Practice Address - Phone:305-332-4168
Practice Address - Fax:305-735-4041
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN4096122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist