Provider Demographics
NPI:1457546848
Name:GORDON, LAURIE SUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:SUE
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 1:2310 YORK ST
Mailing Address - Street 2:4B
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2411
Mailing Address - Country:US
Mailing Address - Phone:708-388-0001
Mailing Address - Fax:708-388-7612
Practice Address - Street 1:2310 YORK ST
Practice Address - Street 2:4B
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2411
Practice Address - Country:US
Practice Address - Phone:708-388-0001
Practice Address - Fax:708-388-7612
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190217211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice