Provider Demographics
NPI:1770716045
Name:GORDON, DAVID ROYCE (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ROYCE
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 1:981 S MAIN ST
Mailing Address - Street 2:SUITE 260
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6053
Mailing Address - Country:US
Mailing Address - Phone:435-787-0222
Mailing Address - Fax:435-787-8499
Practice Address - Street 1:981 S MAIN ST
Practice Address - Street 2:SUITE 260
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-6053
Practice Address - Country:US
Practice Address - Phone:435-787-0222
Practice Address - Fax:435-787-8499
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7389995-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist