Provider Demographics
NPI:1679693550
Name:RICK, GORDON MARVIN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:MARVIN
Last Name:RICK
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:GORDON
Other - Middle Name:
Other - Last Name:RICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5190 GOVERNOR DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-2847
Mailing Address - Country:US
Mailing Address - Phone:858-784-0600
Mailing Address - Fax:858-784-0604
Practice Address - Street 1:5190 GOVERNOR DR
Practice Address - Street 2:SUITE 106
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-2847
Practice Address - Country:US
Practice Address - Phone:858-784-0600
Practice Address - Fax:858-784-0604
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA200411223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology