Provider Demographics
NPI:1497719850
Name:GORDON, LISA A (DMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:GORDON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 BELDEN CT
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1611
Mailing Address - Country:US
Mailing Address - Phone:650-941-2959
Mailing Address - Fax:
Practice Address - Street 1:1993 MCKEE RD
Practice Address - Street 2:DENTAL CLINIC
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1406
Practice Address - Country:US
Practice Address - Phone:408-254-6357
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD42551122300000X
PADS-027340-L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist