Provider Demographics
NPI:1497024475
Name:GORDON, SCOTT MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:MICHAEL
Last Name:GORDON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1238 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-2130
Mailing Address - Country:US
Mailing Address - Phone:570-346-5015
Mailing Address - Fax:570-346-5015
Practice Address - Street 1:1238 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-2130
Practice Address - Country:US
Practice Address - Phone:570-346-5015
Practice Address - Fax:570-346-5015
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO23084L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist