Provider Demographics
NPI:1386643740
Name:GORDON, MARK J (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
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 1:4121 W 83RD ST
Mailing Address - Street 2:SUITE 212
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-5300
Mailing Address - Country:US
Mailing Address - Phone:913-649-4042
Mailing Address - Fax:913-649-8898
Practice Address - Street 1:4121 W 83RD ST
Practice Address - Street 2:SUITE 212
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66208-5300
Practice Address - Country:US
Practice Address - Phone:913-649-4042
Practice Address - Fax:913-649-8898
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5900122300000X
MO013474122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO09533-01-8OtherBCBS
KS79345OtherBCBS