Provider Demographics
NPI:1447738778
Name:SIMON, JORDAN (DMD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1982 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST WYOMING
Mailing Address - State:PA
Mailing Address - Zip Code:18644-9434
Mailing Address - Country:US
Mailing Address - Phone:570-466-2705
Mailing Address - Fax:
Practice Address - Street 1:210 CARVERTON RD
Practice Address - Street 2:
Practice Address - City:TRUCKSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18708-1745
Practice Address - Country:US
Practice Address - Phone:570-696-1105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0418971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice