Provider Demographics
NPI:1073047049
Name:MAYBERRY, JORDAN (DDS)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:MAYBERRY
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 1:305 E 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-2181
Mailing Address - Country:US
Mailing Address - Phone:740-238-1319
Mailing Address - Fax:
Practice Address - Street 1:73 SPORTSMAN DR STE A
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:OH
Practice Address - Zip Code:43334
Practice Address - Country:US
Practice Address - Phone:419-253-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0250481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice