Provider Demographics
NPI:1417963695
Name:JORDAN, JOHN ROSS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROSS
Last Name:JORDAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24069 WOODLAND LN
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7117
Mailing Address - Country:US
Mailing Address - Phone:218-847-8416
Mailing Address - Fax:218-847-5081
Practice Address - Street 1:1106 W RIVER RD
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-2723
Practice Address - Country:US
Practice Address - Phone:218-846-1900
Practice Address - Fax:218-847-5081
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice