Provider Demographics
NPI:1013183292
Name:JORDAN, MICHAEL G (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
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 1:2340 N CLYBOURN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2932
Mailing Address - Country:US
Mailing Address - Phone:773-528-2205
Mailing Address - Fax:773-528-2216
Practice Address - Street 1:2340 N CLYBOURN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2932
Practice Address - Country:US
Practice Address - Phone:773-528-2205
Practice Address - Fax:773-528-2216
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190145911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice