Provider Demographics
NPI:1578803706
Name:JORDAN, THOMAS DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:DAVID
Last Name:JORDAN
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 1:346 FORT ZUMWALT SQ
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-3065
Mailing Address - Country:US
Mailing Address - Phone:636-978-6400
Mailing Address - Fax:636-980-1125
Practice Address - Street 1:346 FORT ZUMWALT SQ
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3065
Practice Address - Country:US
Practice Address - Phone:636-978-6400
Practice Address - Fax:636-980-1125
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO150091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice