Provider Demographics
NPI:1942364005
Name:GORDON J DIEHL DMD PC
Entity Type:Organization
Organization Name:GORDON J DIEHL DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:JOSEF
Authorized Official - Last Name:DIEHL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:631-689-1548
Mailing Address - Street 1:176 GNARLED HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733
Mailing Address - Country:US
Mailing Address - Phone:631-689-1548
Mailing Address - Fax:631-689-1516
Practice Address - Street 1:176 GNARLED HOLLOW ROAD
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733
Practice Address - Country:US
Practice Address - Phone:631-689-1548
Practice Address - Fax:631-689-1516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040755122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty