Provider Demographics
NPI:1679608723
Name:SPARKS, JORDAN SAMUEL (DMD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:SAMUEL
Last Name:SPARKS
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 1:3265 MARIETTA ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-9402
Mailing Address - Country:US
Mailing Address - Phone:503-910-0557
Mailing Address - Fax:
Practice Address - Street 1:3265 MARIETTA ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97317-9402
Practice Address - Country:US
Practice Address - Phone:503-910-0557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD76011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice