1447426317 NPI number — JOURDAN FAMILY DENTISTRY

Table of content: (NPI 1447426317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447426317 NPI number — JOURDAN FAMILY DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOURDAN FAMILY DENTISTRY
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:
Provider Other Organization Name Type Code:
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:
1447426317
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120A W DELAWARE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VINITA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74301-4224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-256-6831
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120A W DELAWARE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VINITA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74301-4224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-256-6831
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JOURDAN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
B
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
918-256-6831

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  5381 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 803040C . This is a "UNITED CONCORDIA" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 263477085001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: OK5381 . This is a "DELTA DENTAL" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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