Provider Demographics
NPI:1609008051
Name:JOHN R JORDAN DDS PA
Entity type:Organization
Organization Name:JOHN R JORDAN DDS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-846-1900
Mailing Address - Street 1:1106 W RIVER RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-2723
Mailing Address - Country:US
Mailing Address - Phone:218-846-1900
Mailing Address - Fax:218-847-5079
Practice Address - Street 1:1106 W RIVER RD
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-2723
Practice Address - Country:US
Practice Address - Phone:218-846-1900
Practice Address - Fax:218-847-5079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-19
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND106891223G0001X
MND124411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty