Provider Demographics
NPI:1598264228
Name:GORDON, ELIZABETH (EPDH)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:EPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 SW SECOND AVE.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-3156
Mailing Address - Country:US
Mailing Address - Phone:503-228-6554
Mailing Address - Fax:
Practice Address - Street 1:601 SW SECOND AVE.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-3156
Practice Address - Country:US
Practice Address - Phone:503-228-6554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5030124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist