Provider Demographics
NPI:1790824944
Name:GORDON, DANIEL BRYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:BRYAN
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 1:6228 GEMINI CT
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-7837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12723 N BELLWOOD DR
Practice Address - Street 2:SUITE 30
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-7275
Practice Address - Country:US
Practice Address - Phone:616-399-8230
Practice Address - Fax:616-399-8374
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010181801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice