Provider Demographics
NPI:1275630402
Name:GORDON, ROBERT L (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
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 1:11 S MAIN ST
Mailing Address - Street 2:PO BOX 593
Mailing Address - City:EAST GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06026
Mailing Address - Country:US
Mailing Address - Phone:860-653-2636
Mailing Address - Fax:860-653-1960
Practice Address - Street 1:11 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06026
Practice Address - Country:US
Practice Address - Phone:860-653-2636
Practice Address - Fax:860-653-1960
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT 4514122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist