Provider Demographics
NPI:1376781864
Name:JEREMIAH D GORDON, DMD, PA
Entity Type:Organization
Organization Name:JEREMIAH D GORDON, DMD, PA
Other - Org Name:GORDON DENTAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIS/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:D
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-460-0999
Mailing Address - Street 1:135 JENKINS ST
Mailing Address - Street 2:SUITE 105A
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5175
Mailing Address - Country:US
Mailing Address - Phone:904-460-0999
Mailing Address - Fax:
Practice Address - Street 1:53 WILLOW DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-5936
Practice Address - Country:US
Practice Address - Phone:904-471-5336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL163481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty