Provider Demographics
NPI:1205418456
Name:JORDAN, RUTH
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1988 VAN VOORHIS ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:FORT EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23604-1409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:577 STERNBERG AVE
Practice Address - Street 2:
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-1526
Practice Address - Country:US
Practice Address - Phone:757-314-7825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant