Provider Demographics
NPI:1184704587
Name:GORDON, KATHLEEN ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANN
Last Name:GORDON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 RICE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-0143
Mailing Address - Country:US
Mailing Address - Phone:951-682-0042
Mailing Address - Fax:951-682-0043
Practice Address - Street 1:4515 CENTRAL AVE STE 103
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2374
Practice Address - Country:US
Practice Address - Phone:951-682-0042
Practice Address - Fax:951-682-0043
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA426551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice