Provider Demographics
NPI:1215184692
Name:GORDON, WANDA CELESTE (DMD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:CELESTE
Last Name:GORDON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3223 N BROAD ST
Mailing Address - Street 2:DEPARTMENT OF ENDODONTICS
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-5007
Mailing Address - Country:US
Mailing Address - Phone:215-707-4428
Mailing Address - Fax:215-707-1482
Practice Address - Street 1:3223 N BROAD ST
Practice Address - Street 2:DEPARTMENT OF ENDODONTICS
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5007
Practice Address - Country:US
Practice Address - Phone:215-707-4428
Practice Address - Fax:215-707-1482
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024105L1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics