Provider Demographics
NPI:1689059313
Name:WEIS, JORDAN (DMD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WEIS
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 1:2102 W RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-1973
Mailing Address - Country:US
Mailing Address - Phone:618-283-4900
Mailing Address - Fax:618-283-4963
Practice Address - Street 1:2102 W RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1973
Practice Address - Country:US
Practice Address - Phone:618-283-4900
Practice Address - Fax:618-283-4963
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030323122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist