Provider Demographics
NPI:1609899368
Name:JORDAN, HUGH FREDERICK (DDS,)
Entity Type:Individual
Prefix:
First Name:HUGH
Middle Name:FREDERICK
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 1:401 DURDEN ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-4600
Mailing Address - Country:US
Mailing Address - Phone:912-537-7211
Mailing Address - Fax:912-537-1011
Practice Address - Street 1:401 DURDEN ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-4600
Practice Address - Country:US
Practice Address - Phone:912-537-7211
Practice Address - Fax:912-537-1011
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA85141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00089702BMedicaid
GA00089702BMedicaid