Provider Demographics
NPI:1295129864
Name:GORDON, ELIZABETH MIRIAM (DMD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:MIRIAM
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 1:2609 W OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33311-1355
Mailing Address - Country:US
Mailing Address - Phone:954-485-1170
Mailing Address - Fax:
Practice Address - Street 1:2609 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33311-1355
Practice Address - Country:US
Practice Address - Phone:954-485-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 210721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice