Provider Demographics
NPI:1407055981
Name:RUTHERFORD, JORDAN G
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:G
Last Name:RUTHERFORD
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 1:51 DAVID DR
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-9440
Mailing Address - Country:US
Mailing Address - Phone:970-731-3627
Mailing Address - Fax:970-731-2395
Practice Address - Street 1:51 DAVID DR
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-9440
Practice Address - Country:US
Practice Address - Phone:970-731-3627
Practice Address - Fax:970-731-2395
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN-94571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice