Provider Demographics
NPI:1740356286
Name:JORDONNE, WILLY JP (DDS)
Entity type:Individual
Prefix:DR
First Name:WILLY
Middle Name:JP
Last Name:JORDONNE
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 1:1177 NOSTRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-5911
Mailing Address - Country:US
Mailing Address - Phone:718-953-1043
Mailing Address - Fax:718-953-3550
Practice Address - Street 1:72 BORGLUM RD
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-2123
Practice Address - Country:US
Practice Address - Phone:516-365-5561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0406401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01005774Medicaid