Provider Demographics
NPI:1790263887
Name:JORDAN GADDIS D.D.S. A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:JORDAN GADDIS D.D.S. A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GADDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-206-6902
Mailing Address - Street 1:2835 EASTERN AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-5400
Mailing Address - Country:US
Mailing Address - Phone:916-486-8558
Mailing Address - Fax:
Practice Address - Street 1:2835 EASTERN AVE STE 3
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-5400
Practice Address - Country:US
Practice Address - Phone:916-486-8558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101617261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental