Provider Demographics
NPI:1225706930
Name:SIMPSON, JORDAN MARC
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MARC
Last Name:SIMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3235 THE COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-9740
Mailing Address - Country:US
Mailing Address - Phone:954-668-8203
Mailing Address - Fax:
Practice Address - Street 1:4168 BAKER ST NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1404
Practice Address - Country:US
Practice Address - Phone:770-787-2230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN122464.1223G0001X
GADN122464122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice