Provider Demographics
NPI:1497870646
Name:GORDON, JEREMIAH DANIEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:DANIEL
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 1:53 WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-5936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 JENKINS ST
Practice Address - Street 2:SUITE 105A
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5175
Practice Address - Country:US
Practice Address - Phone:904-460-0999
Practice Address - Fax:904-460-0999
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16348122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist