Provider Demographics
NPI:1477301067
Name:WACHTER, JORDAN RUSSELL
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:RUSSELL
Last Name:WACHTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 SE 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2269
Mailing Address - Country:US
Mailing Address - Phone:602-369-9845
Mailing Address - Fax:
Practice Address - Street 1:8535 E HARTFORD DR STE 202
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-5444
Practice Address - Country:US
Practice Address - Phone:480-515-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-08
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD012276122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist