Provider Demographics
NPI:1871565374
Name:JORDAN, CHARLES J (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
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 1:1425 W GRAND AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:HAYSVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67060-1270
Mailing Address - Country:US
Mailing Address - Phone:316-524-8661
Mailing Address - Fax:316-524-0331
Practice Address - Street 1:1425 W GRAND AVE STE 101
Practice Address - Street 2:
Practice Address - City:HAYSVILLE
Practice Address - State:KS
Practice Address - Zip Code:67060-1270
Practice Address - Country:US
Practice Address - Phone:316-524-8661
Practice Address - Fax:316-524-0331
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS69661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice