Provider Demographics
NPI:1609993898
Name:JORDAN, MILLARD DENNIS (DDS)
Entity type:Individual
Prefix:
First Name:MILLARD
Middle Name:DENNIS
Last Name:JORDAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17563 GREENFIELD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235
Mailing Address - Country:US
Mailing Address - Phone:313-272-0118
Mailing Address - Fax:313-272-0488
Practice Address - Street 1:17563 GREENFIELD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235
Practice Address - Country:US
Practice Address - Phone:313-272-0118
Practice Address - Fax:313-272-0488
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901012336122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4053791Medicaid