Provider Demographics
NPI:1639418254
Name:HOTTENSTEIN, JORDAN DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:DAVID
Last Name:HOTTENSTEIN
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:PO BOX 724
Mailing Address - Street 2:FIRST AND PEACH STREETS
Mailing Address - City:LEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:19533-0724
Mailing Address - Country:US
Mailing Address - Phone:610-926-5705
Mailing Address - Fax:610-926-6446
Practice Address - Street 1:FIRST AND PEACH STREETS
Practice Address - Street 2:
Practice Address - City:LEESPORT
Practice Address - State:PA
Practice Address - Zip Code:19533-0724
Practice Address - Country:US
Practice Address - Phone:610-926-5705
Practice Address - Fax:610-926-6446
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS 0378621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice