Provider Demographics
NPI:1033737374
Name:RABBAN, JORDAN
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:RABBAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 CHERRY BLOSSOM CIR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-1297
Mailing Address - Country:US
Mailing Address - Phone:248-231-4567
Mailing Address - Fax:
Practice Address - Street 1:18181 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2666
Practice Address - Country:US
Practice Address - Phone:248-557-5756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600603122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist