Provider Demographics
NPI:1750516159
Name:GORDON, STEPHANIE SPURLOCK
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SPURLOCK
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 NE 54TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-2822
Mailing Address - Country:US
Mailing Address - Phone:786-344-6583
Mailing Address - Fax:
Practice Address - Street 1:1245 NW 119TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33167-3231
Practice Address - Country:US
Practice Address - Phone:305-685-7863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-29
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18410124Q00000X
FLDH 18410124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist