Provider Demographics
NPI:1750714119
Name:GORDON, MELINDA PIEGA (DMD)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:PIEGA
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 1:16935 VANOWEN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAKE BALBOA
Mailing Address - State:CA
Mailing Address - Zip Code:91406-4595
Mailing Address - Country:US
Mailing Address - Phone:818-705-2931
Mailing Address - Fax:818-344-9565
Practice Address - Street 1:16935 VANOWEN ST
Practice Address - Street 2:SUITE A
Practice Address - City:LAKE BALBOA
Practice Address - State:CA
Practice Address - Zip Code:91406-4595
Practice Address - Country:US
Practice Address - Phone:818-705-2931
Practice Address - Fax:818-705-2931
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32605122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist