Provider Demographics
NPI:1043467152
Name:NORD, JACKIE RAE (DDS)
Entity type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:RAE
Last Name:NORD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 S 4TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4781
Mailing Address - Country:US
Mailing Address - Phone:701-757-2100
Mailing Address - Fax:701-757-0305
Practice Address - Street 1:212 S 4TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4777
Practice Address - Country:US
Practice Address - Phone:701-757-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2108122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1043467152Medicaid
ND40011Medicaid