Provider Demographics
NPI:1134743925
Name:GORDON, TYLER ANNA (DMD)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:ANNA
Last Name:GORDON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W 7TH ST APT 2434
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-1671
Mailing Address - Country:US
Mailing Address - Phone:910-777-9053
Mailing Address - Fax:
Practice Address - Street 1:203 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-3831
Practice Address - Country:US
Practice Address - Phone:704-825-9635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC118621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice