Provider Demographics
NPI:1407145022
Name:DAMON, GORDON CLARK JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:CLARK
Last Name:DAMON
Suffix:JR
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 1:1414 TEXAS ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-3426
Mailing Address - Country:US
Mailing Address - Phone:817-336-2121
Mailing Address - Fax:
Practice Address - Street 1:1414 TEXAS ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-3426
Practice Address - Country:US
Practice Address - Phone:817-336-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX271471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice