Provider Demographics
NPI:1376821546
Name:NORDSTROM, MORGAN D (DDS)
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:D
Last Name:NORDSTROM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 TENNESSEE ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-4627
Mailing Address - Country:US
Mailing Address - Phone:707-643-2660
Mailing Address - Fax:
Practice Address - Street 1:1528 TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-4627
Practice Address - Country:US
Practice Address - Phone:707-643-2660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-22
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61580122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist