Provider Demographics
NPI:1083662415
Name:JORDAN, CLIFTON III (DDS)
Entity Type:Individual
Prefix:
First Name:CLIFTON
Middle Name:
Last Name:JORDAN
Suffix:III
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 1:2197 SAINT MATTHEWS RD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2038
Mailing Address - Country:US
Mailing Address - Phone:803-531-1601
Mailing Address - Fax:
Practice Address - Street 1:2197 SAINT MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2038
Practice Address - Country:US
Practice Address - Phone:803-531-1601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40101223G0001X
SCSC4010122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4010Medicaid