Provider Demographics
NPI:1659487601
Name:GORDON, JODIE LYDELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JODIE
Middle Name:LYDELL
Last Name:GORDON
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 1:1525 N NEW ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2472
Mailing Address - Country:US
Mailing Address - Phone:660-665-7908
Mailing Address - Fax:660-665-9399
Practice Address - Street 1:1525 N NEW ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-2472
Practice Address - Country:US
Practice Address - Phone:660-665-7908
Practice Address - Fax:660-665-9399
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0149301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice