Provider Demographics
NPI:1275850067
Name:JORDAN, KEVIN R (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:JORDAN
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 1:154 SCOTT ST.
Mailing Address - Street 2:
Mailing Address - City:OLIVE HILL
Mailing Address - State:KY
Mailing Address - Zip Code:41164
Mailing Address - Country:US
Mailing Address - Phone:606-286-4142
Mailing Address - Fax:
Practice Address - Street 1:154 SCOTT ST.
Practice Address - Street 2:
Practice Address - City:OLIVE HILL
Practice Address - State:KY
Practice Address - Zip Code:41164
Practice Address - Country:US
Practice Address - Phone:606-286-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY6868122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist