Provider Demographics
NPI:1851062111
Name:DEMARTELAERE, JORDAN NICOLE
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:NICOLE
Last Name:DEMARTELAERE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25201 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:CALUMET
Mailing Address - State:MI
Mailing Address - Zip Code:49913-1326
Mailing Address - Country:US
Mailing Address - Phone:517-285-9877
Mailing Address - Fax:
Practice Address - Street 1:56720 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:CALUMET
Practice Address - State:MI
Practice Address - Zip Code:49913-1967
Practice Address - Country:US
Practice Address - Phone:906-483-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-25
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI19184080736124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist