Provider Demographics
NPI:1174185854
Name:JORGENSON, CODY GRANT (DDS)
Entity Type:Individual
Prefix:DR
First Name:CODY
Middle Name:GRANT
Last Name:JORGENSON
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 1:340 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SLINGER
Mailing Address - State:WI
Mailing Address - Zip Code:53086-9587
Mailing Address - Country:US
Mailing Address - Phone:262-644-6921
Mailing Address - Fax:262-644-6926
Practice Address - Street 1:340 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SLINGER
Practice Address - State:WI
Practice Address - Zip Code:53086-9587
Practice Address - Country:US
Practice Address - Phone:262-644-6921
Practice Address - Fax:262-644-6926
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001299-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty