Provider Demographics
NPI:1043983562
Name:SPAVOR, JORDAN MITCHELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:MITCHELL
Last Name:SPAVOR
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 1:8022 LAKE WOOD DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-5565
Mailing Address - Country:US
Mailing Address - Phone:313-571-4008
Mailing Address - Fax:
Practice Address - Street 1:260 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MI
Practice Address - Zip Code:49064-9325
Practice Address - Country:US
Practice Address - Phone:269-621-3143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601054122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist