Provider Demographics
NPI:1194218776
Name:CARL, JORDAN MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:MICHAEL
Last Name:CARL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 KATHRYN DR STE A
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-4200
Mailing Address - Country:US
Mailing Address - Phone:972-221-9136
Mailing Address - Fax:
Practice Address - Street 1:105 KATHRYN DR STE A
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-4200
Practice Address - Country:US
Practice Address - Phone:972-221-9136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363701223G0001X
CA1024411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty