Provider Demographics
NPI:1033686464
Name:JORDAN, KATIE (RDH)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18190 RAINBOW DR
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4518
Mailing Address - Country:US
Mailing Address - Phone:313-505-6665
Mailing Address - Fax:248-864-8648
Practice Address - Street 1:18190 RAINBOW DR
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-4518
Practice Address - Country:US
Practice Address - Phone:313-505-6665
Practice Address - Fax:248-864-8648
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902012177124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist