Provider Demographics
NPI:1891009346
Name:JORDAN, EBONY (DDS)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3213
Mailing Address - Country:US
Mailing Address - Phone:626-669-4655
Mailing Address - Fax:
Practice Address - Street 1:1427 MISSION ST
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3213
Practice Address - Country:US
Practice Address - Phone:626-403-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012022A1223P0221X, 122300000X
CADDS1034621223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist