Provider Demographics
NPI:1790464022
Name:JORDAN, JUSTIN RICHARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:RICHARD
Last Name:JORDAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:MR
Other - First Name:JUSTIN
Other - Middle Name:RICHARD
Other - Last Name:KOWALSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1667 COCHRANE CIR BLDG 7495
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1667 COCHRANE CIR BLDG 7495
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4603
Practice Address - Country:US
Practice Address - Phone:719-526-5537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13486282-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist