Provider Demographics
NPI:1043847874
Name:JORDAN, CODY
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24069 WOODLAND LN
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7105
Mailing Address - Country:US
Mailing Address - Phone:218-849-1537
Mailing Address - Fax:
Practice Address - Street 1:14199 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8462
Practice Address - Country:US
Practice Address - Phone:218-203-9872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MNS2211223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program