Provider Demographics
NPI:1083073522
Name:ENDRES, JORDAN (DDS)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:ENDRES
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 1:1116 SE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-4360
Mailing Address - Country:US
Mailing Address - Phone:480-286-1188
Mailing Address - Fax:
Practice Address - Street 1:150 NE KENNETH FORD DR
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1042
Practice Address - Country:US
Practice Address - Phone:541-672-9596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-12
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARR60578878390200000X
ORD104321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program