Provider Demographics
NPI:1629183116
Name:GRUEN, GORDON ERNEST (DDS)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:ERNEST
Last Name:GRUEN
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 1:780 RIDGE LAKE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9426
Mailing Address - Country:US
Mailing Address - Phone:901-682-8431
Mailing Address - Fax:901-682-2345
Practice Address - Street 1:780 RIDGE LAKE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-9426
Practice Address - Country:US
Practice Address - Phone:901-682-8431
Practice Address - Fax:901-682-2345
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS 17831223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2007914OtherBLUE CROSS BLUE SHIELD
TNT74116Medicare UPIN
TN3-20365-9Medicare ID - Type Unspecified