Provider Demographics
NPI:1255448767
Name:GORDON, JONATHAN MELVIN
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MELVIN
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 N CAMDEN DR
Mailing Address - Street 2:SUITE 1260
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4532
Mailing Address - Country:US
Mailing Address - Phone:310-859-8123
Mailing Address - Fax:310-859-2884
Practice Address - Street 1:414 N CAMDEN DR
Practice Address - Street 2:SUITE 1260
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4532
Practice Address - Country:US
Practice Address - Phone:310-859-8123
Practice Address - Fax:310-859-2884
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA349261223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics