Provider Demographics
NPI:1548203508
Name:GORDAN, DENNIS S (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:S
Last Name:GORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4700
Mailing Address - Country:US
Mailing Address - Phone:860-444-4739
Mailing Address - Fax:860-442-0262
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-444-4739
Practice Address - Fax:860-442-0262
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036813174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB73785Medicare UPIN