Provider Demographics
NPI:1013403963
Name:BLUMENTHAL, JORDAN SCOTT (DMD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:SCOTT
Last Name:BLUMENTHAL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 COLTON RD
Mailing Address - Street 2:
Mailing Address - City:GLADWYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19035-1104
Mailing Address - Country:US
Mailing Address - Phone:610-999-5501
Mailing Address - Fax:
Practice Address - Street 1:6 ORIOLE AVE
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-4515
Practice Address - Country:US
Practice Address - Phone:610-679-6109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO417681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty