Provider Demographics
NPI:1598285538
Name:VAN GORDON, OLIVIA MCDANIEL
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MCDANIEL
Last Name:VAN GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 F S HILL DR STE A
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5071
Mailing Address - Country:US
Mailing Address - Phone:662-226-1757
Mailing Address - Fax:662-307-2709
Practice Address - Street 1:1800 F S HILL DR STE A
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5071
Practice Address - Country:US
Practice Address - Phone:662-226-1757
Practice Address - Fax:662-307-2709
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3934-171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty