Provider Demographics
NPI:1457626806
Name:TORTORICH, JORDAN A
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:A
Last Name:TORTORICH
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 1:4220 N RODNEY PARHAM RD STE 103
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-2466
Mailing Address - Country:US
Mailing Address - Phone:501-224-8332
Mailing Address - Fax:501-219-8003
Practice Address - Street 1:4220 N RODNEY PARHAM RD STE 103
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-2466
Practice Address - Country:US
Practice Address - Phone:501-224-8332
Practice Address - Fax:501-219-8003
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA401291223G0001X
IADDS-091381223S0112X
AR44201223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice