Provider Demographics
NPI:1053632901
Name:JORDAN, DASHIELL (MD)
Entity Type:Individual
Prefix:
First Name:DASHIELL
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DASHIELL
Other - Middle Name:J
Other - Last Name:SLABBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1638
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-1638
Mailing Address - Country:US
Mailing Address - Phone:207-777-4111
Mailing Address - Fax:207-783-6660
Practice Address - Street 1:99 CAMPUS AVE STE 201
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6045
Practice Address - Country:US
Practice Address - Phone:207-777-8810
Practice Address - Fax:207-777-8155
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
METD171104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1053632901Medicaid
ME1053632901Medicaid