Provider Demographics
NPI:1760542302
Name:GORDON, AUDREY E (D D S)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:E
Last Name:GORDON
Suffix:
Gender:F
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-6043
Mailing Address - Country:US
Mailing Address - Phone:803-536-0405
Mailing Address - Fax:803-536-3533
Practice Address - Street 1:157 CENTRE ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-6043
Practice Address - Country:US
Practice Address - Phone:803-536-0405
Practice Address - Fax:803-536-3533
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33971223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry