Provider Demographics
NPI:1558301366
Name:GORDON, DENNIS H (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:H
Last Name:GORDON
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:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-0150
Mailing Address - Country:US
Mailing Address - Phone:801-601-2825
Mailing Address - Fax:801-562-3169
Practice Address - Street 1:3336 PIONEER PKWY
Practice Address - Street 2:SUITE 203
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2000
Practice Address - Country:US
Practice Address - Phone:801-964-3925
Practice Address - Fax:801-964-3928
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT149427-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1558301366Medicaid
D07686Medicare UPIN