Provider Demographics
NPI:1508850934
Name:GORDON, GLENN E (DDS)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:E
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 1:403 E MEEKER ST
Mailing Address - Street 2:STE 300
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-5904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16345 NE 87TH ST
Practice Address - Street 2:STE C-2
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3503
Practice Address - Country:US
Practice Address - Phone:425-883-8000
Practice Address - Fax:425-883-7580
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000059951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice