1245405877 NPI number — JORDAN DENTAL GROUP INC

Table of content: (NPI 1245405877)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245405877 NPI number — JORDAN DENTAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JORDAN DENTAL GROUP INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BRUCE M JORDAN DDS, INC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245405877
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 130939
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARLSBAD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92013-0939
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-438-0948
Provider Business Mailing Address Fax Number:
760-438-7821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6120 PASEO DEL NORTE
Provider Second Line Business Practice Location Address:
K1
Provider Business Practice Location Address City Name:
CARLSBAD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92011-1150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-438-0948
Provider Business Practice Location Address Fax Number:
760-438-7821
Provider Enumeration Date:
04/24/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
OFFICE COORDINATOR
Authorized Official Telephone Number:
760-438-0948

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  28010 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)