Provider Demographics
NPI:1922747377
Name:DA COSTA, JORDAN DEAN (DMD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:DEAN
Last Name:DA COSTA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17225 LOSILLAS CIR UNIT 736
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-9574
Mailing Address - Country:US
Mailing Address - Phone:954-536-3058
Mailing Address - Fax:
Practice Address - Street 1:6871 DANIELS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-1510
Practice Address - Country:US
Practice Address - Phone:239-288-0537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN27037122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program