Provider Demographics
NPI:1982922746
Name:GORDEN, MARK WILLIAM (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:GORDEN
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 1:754 E CITRUS AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374
Mailing Address - Country:US
Mailing Address - Phone:909-793-1158
Mailing Address - Fax:909-793-8840
Practice Address - Street 1:754 E CITRUS AVE
Practice Address - Street 2:REDLANDS
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374
Practice Address - Country:US
Practice Address - Phone:909-793-8840
Practice Address - Fax:909-793-8840
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26067122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist