Provider Demographics
NPI:1558617316
Name:MARTIN, JORDAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:MARTIN
Suffix:
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 1:9136 BONITA BEACH RD SE
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-4281
Mailing Address - Country:US
Mailing Address - Phone:239-992-9229
Mailing Address - Fax:
Practice Address - Street 1:9136 BONITA BEACH RD SE
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4281
Practice Address - Country:US
Practice Address - Phone:239-992-9229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19896122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist