Provider Demographics
NPI:1932371259
Name:GORDON, JEFFREY GLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:GLEN
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:PO BOX 29052
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-0052
Mailing Address - Country:US
Mailing Address - Phone:773-445-3337
Mailing Address - Fax:773-445-3340
Practice Address - Street 1:8244 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-3329
Practice Address - Country:US
Practice Address - Phone:773-445-3337
Practice Address - Fax:773-445-3340
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190233831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice