Provider Demographics
NPI:1588025324
Name:BERRY, JORDAN ANTHONY (DMD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ANTHONY
Last Name:BERRY
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 1:4006 GRAY HERON DR
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-9547
Mailing Address - Country:US
Mailing Address - Phone:843-230-7495
Mailing Address - Fax:
Practice Address - Street 1:675 WACHESAW RD UNIT C
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5681
Practice Address - Country:US
Practice Address - Phone:843-230-7495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC88001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program