Provider Demographics
NPI:1609943109
Name:JORDAN, BRIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
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 1:697 WILDER ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1334
Mailing Address - Country:US
Mailing Address - Phone:651-699-2415
Mailing Address - Fax:
Practice Address - Street 1:7501 GOLDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4563
Practice Address - Country:US
Practice Address - Phone:763-544-2213
Practice Address - Fax:763-541-1758
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice