Provider Demographics
NPI:1942217799
Name:JORDAN, NANCY WISE (DDS)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:WISE
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:PO BOX 308
Mailing Address - Street 2:108 6TH ST
Mailing Address - City:GROTTOES
Mailing Address - State:VA
Mailing Address - Zip Code:24441
Mailing Address - Country:US
Mailing Address - Phone:540-249-4242
Mailing Address - Fax:540-249-4732
Practice Address - Street 1:108 6TH ST
Practice Address - Street 2:
Practice Address - City:GROTTOES
Practice Address - State:VA
Practice Address - Zip Code:24441
Practice Address - Country:US
Practice Address - Phone:540-249-4242
Practice Address - Fax:540-249-4732
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401006821122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist