Provider Demographics
NPI:1134780125
Name:ROBERTS, JORDAN JACOB (DDS)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:JACOB
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 ERIE ST SE APT 302
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3047
Mailing Address - Country:US
Mailing Address - Phone:218-850-0590
Mailing Address - Fax:
Practice Address - Street 1:401 RAILROAD ST W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4109
Practice Address - Country:US
Practice Address - Phone:406-258-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT173911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice