Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 22DI02593900 | NJ |
N | 1223X0400X | Orthodontists | DS042522 | PA |
NPI | 1023449352 |
---|---|
Provider Name | Dr. Colleen Mohan Gordon |
First Address | Marlton, NJ 08053-5623 |
Second Address | Ambler, PA 19002-2557 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/12/2013 |
Last Update Date | 19/07/2020 |