Provider Demographics
NPI:1750491866
Name:GORDON, JOHN LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LYNN
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 1:1315 SOUTH 8TH
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030
Mailing Address - Country:US
Mailing Address - Phone:505-546-6591
Mailing Address - Fax:505-546-4376
Practice Address - Street 1:1315 SOUTH 8TH
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030
Practice Address - Country:US
Practice Address - Phone:505-546-6591
Practice Address - Fax:505-546-4376
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDL1352122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist