Provider Demographics
NPI:1063242691
Name:BROCK A VAN GORDON DMD, PC
Entity type:Organization
Organization Name:BROCK A VAN GORDON DMD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:ASHLEY
Authorized Official - Last Name:VAN GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-730-4924
Mailing Address - Street 1:6485 SW BORLAND RD STE G
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9762
Mailing Address - Country:US
Mailing Address - Phone:503-878-4163
Mailing Address - Fax:833-438-7620
Practice Address - Street 1:6485 SW BORLAND RD STE G
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9762
Practice Address - Country:US
Practice Address - Phone:503-878-4163
Practice Address - Fax:833-438-7620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-07
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental