Provider Demographics
NPI:1518516392
Name:JORDAN, CHARLES (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 GREEN ACRES DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8531
Mailing Address - Country:US
Mailing Address - Phone:912-293-4642
Mailing Address - Fax:
Practice Address - Street 1:412 NORTHSIDE DR E
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4802
Practice Address - Country:US
Practice Address - Phone:912-225-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015930122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
053162016OtherDRIVERS LICENSE