Provider Demographics
NPI:1265591382
Name:GORDON, MATHEW CHARLES (MD DDS)
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:CHARLES
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 DEVINE RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2527
Mailing Address - Country:US
Mailing Address - Phone:210-824-4501
Mailing Address - Fax:210-824-0125
Practice Address - Street 1:235 E HILDEBRAND AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2430
Practice Address - Country:US
Practice Address - Phone:210-824-4501
Practice Address - Fax:210-824-0125
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK65941223S0112X
TX168341223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG74383Medicare UPIN
TX0877DMedicare ID - Type Unspecified