Provider Demographics
NPI:1619531134
Name:BOOTH, JORDAN (DDS)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BOOTH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2744 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-3246
Mailing Address - Country:US
Mailing Address - Phone:812-569-3672
Mailing Address - Fax:
Practice Address - Street 1:4873 PORT ROYAL RD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:TN
Practice Address - Zip Code:37174-2799
Practice Address - Country:US
Practice Address - Phone:931-486-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program