Provider Demographics
NPI:1790903771
Name:JORDAN, RALPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:
Last Name:JORDAN
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 1:11312 SUNDIAL CT.
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20194
Mailing Address - Country:US
Mailing Address - Phone:703-435-4747
Mailing Address - Fax:
Practice Address - Street 1:1451 BELLE HAVEN RD
Practice Address - Street 2:SUITE 430
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22307-1201
Practice Address - Country:US
Practice Address - Phone:703-765-7777
Practice Address - Fax:703-765-7794
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA4110122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist