Provider Demographics
NPI:1215190731
Name:GORDON, MANUEL BARRY
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:BARRY
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MANUEL
Other - Middle Name:BARRY
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:160 E 91ST ST
Mailing Address - Street 2:2N
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-2452
Mailing Address - Country:US
Mailing Address - Phone:646-483-4470
Mailing Address - Fax:
Practice Address - Street 1:370 W PLEASANTVIEW AVE STE 14A
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-8004
Practice Address - Country:US
Practice Address - Phone:646-483-4470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI021851001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty