Provider Demographics
NPI:1508086455
Name:JORDAN DENTAL CARE, P.A.
Entity Type:Organization
Organization Name:JORDAN DENTAL CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:THELEMANN-ZUNIGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-492-2021
Mailing Address - Street 1:224 BROADWAY ST S
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:MN
Mailing Address - Zip Code:55352-1557
Mailing Address - Country:US
Mailing Address - Phone:952-492-2021
Mailing Address - Fax:952-492-6505
Practice Address - Street 1:224 BROADWAY ST S
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:MN
Practice Address - Zip Code:55352-1557
Practice Address - Country:US
Practice Address - Phone:952-492-2021
Practice Address - Fax:952-492-6505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND118041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty