Provider Demographics
NPI:1851377014
Name:ORDAHL, JOHN N SR (DDSMS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:N
Last Name:ORDAHL
Suffix:SR
Gender:M
Credentials:DDSMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 AUSTIN BLUFFS PKWY SUIET 215
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918
Mailing Address - Country:US
Mailing Address - Phone:719-596-3098
Mailing Address - Fax:719-596-3009
Practice Address - Street 1:3505 AUSTIN BLUFFS PKWY SUIET 215
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918
Practice Address - Country:US
Practice Address - Phone:719-596-3098
Practice Address - Fax:719-596-3009
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO54621223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0005233146OtherAETNA DMO
CO794996OtherUNITED CONCORDIA
CO1801027925Medicaid
CO02054625Medicaid