Individual
BRIAN KEITH GORDON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
620 JOHN PAUL JONES CIR STE 275, PORTSMOUTH, VA 23708-2197
(757) 953-7550
Mailing address
2054 W 1600 N, PROVO, UT 84604-2282
(801) 636-1616
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
12315200-9921
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0401419116
DENTAL LICENSE
VA
01
—
12315200-9921
DENTAL LICENSE
UT
Enumeration date
07/22/2021
Last updated
07/23/2024
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