Provider Demographics
NPI:1285713263
Name:GORDON, JEFFREY H I (DMD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:H
Last Name:GORDON
Suffix:I
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1764 UINTA WAY STE E1
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-7674
Mailing Address - Country:US
Mailing Address - Phone:435-647-3012
Mailing Address - Fax:435-645-9873
Practice Address - Street 1:1764 UINTA WAY STE E1
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7674
Practice Address - Country:US
Practice Address - Phone:435-647-3012
Practice Address - Fax:435-645-9873
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00110821223G0001X
UT63777311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice