Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 22399 | CA |
NPI | 1124351358 |
---|---|
Provider Name | Dr. Gordon Lee Pattison III |
First Address | Los Angeles, CA 90025-6616 |
Second Address | Los Angeles, CA 90025-6616 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/09/2009 |
Last Update Date | 04/09/2009 |