Provider Demographics
NPI:1053412718
Name:CALLISON, GORDON MATHEW (DDS)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:MATHEW
Last Name:CALLISON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:438 S ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6310
Mailing Address - Country:US
Mailing Address - Phone:708-508-0437
Mailing Address - Fax:312-569-8089
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:JESSE BROWN VAMC DENTAL SERVICE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-569-6669
Practice Address - Fax:312-569-8089
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics