Provider Demographics
NPI:1245405877
Name:JORDAN DENTAL GROUP INC
Entity Type:Organization
Organization Name:JORDAN DENTAL GROUP INC
Other - Org Name:BRUCE M JORDAN DDS, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:760-438-0948
Mailing Address - Street 1:PO BOX 130939
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92013-0939
Mailing Address - Country:US
Mailing Address - Phone:760-438-0948
Mailing Address - Fax:760-438-7821
Practice Address - Street 1:6120 PASEO DEL NORTE
Practice Address - Street 2:K1
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1150
Practice Address - Country:US
Practice Address - Phone:760-438-0948
Practice Address - Fax:760-438-7821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA280101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty