Provider Demographics
NPI:1407851702
Name:GORDON, MICHAEL LEWIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEWIS
Last Name:GORDON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3544 SPRINGDALE RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45251-1331
Mailing Address - Country:US
Mailing Address - Phone:513-385-6555
Mailing Address - Fax:513-385-2833
Practice Address - Street 1:3544 SPRINGDALE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45251-1331
Practice Address - Country:US
Practice Address - Phone:513-385-6555
Practice Address - Fax:513-385-2833
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2007-07-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
OH300140841223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0215565Medicaid