Provider Demographics
NPI:1235352543
Name:GORDON, LESLIE R (DDS)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:R
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 1:3240 RIVER VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-8090
Mailing Address - Country:US
Mailing Address - Phone:901-544-7600
Mailing Address - Fax:901-544-7602
Practice Address - Street 1:814 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-5041
Practice Address - Country:US
Practice Address - Phone:901-544-7597
Practice Address - Fax:901-544-7602
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS8483122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDS8483OtherDENTIST LICENSE