Provider Demographics
NPI:1356441612
Name:GORDON FORMICA & LOVE DDS PA
Entity Type:Organization
Organization Name:GORDON FORMICA & LOVE DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRES
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:FORMICA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-262-3535
Mailing Address - Street 1:3233 SUPERIOR LANE
Mailing Address - Street 2:B-25
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715
Mailing Address - Country:US
Mailing Address - Phone:301-262-3535
Mailing Address - Fax:301-464-3478
Practice Address - Street 1:3233 SUPERIOR LANE
Practice Address - Street 2:B-25
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715
Practice Address - Country:US
Practice Address - Phone:301-262-3535
Practice Address - Fax:301-464-3478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03909122300000X
MD04017122300000X
MD04497122300000X
MD12848122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty