Provider Demographics
NPI:1508018615
Name:JORDAN, DAVID MCGRAIN II (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MCGRAIN
Last Name:JORDAN
Suffix:II
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 1:1724 BROAD RIPPLE AVE.
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220
Mailing Address - Country:US
Mailing Address - Phone:317-257-6549
Mailing Address - Fax:
Practice Address - Street 1:1724 BROAD RIPPLE AVE.
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220
Practice Address - Country:US
Practice Address - Phone:317-257-6549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007199A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100060140AMedicaid