Provider Demographics
NPI:1265480594
Name:HOLDER, GORDON ORVILLE (DDS)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:ORVILLE
Last Name:HOLDER
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 1:76 BELVIDERE AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-2400
Mailing Address - Country:US
Mailing Address - Phone:860-558-5330
Mailing Address - Fax:
Practice Address - Street 1:336 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-1203
Practice Address - Country:US
Practice Address - Phone:188-281-5975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0065121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002065127Medicaid