Provider Demographics
NPI:1508578568
Name:LANDAU, JORDAN DAVID
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:DAVID
Last Name:LANDAU
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 1:7220 RIVER WALK DR APT K
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-4614
Mailing Address - Country:US
Mailing Address - Phone:317-696-5744
Mailing Address - Fax:
Practice Address - Street 1:435 VIRGINIA AVE UNIT 1800
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-0016
Practice Address - Country:US
Practice Address - Phone:317-672-7522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013880A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist