Provider Demographics
NPI:1639866213
Name:JORDAN, SCOTT RICHARD (DMD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:RICHARD
Last Name:JORDAN
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-467-4431
Mailing Address - Fax:208-466-5359
Practice Address - Street 1:201 S PARADISE AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644-5809
Practice Address - Country:US
Practice Address - Phone:208-585-0048
Practice Address - Fax:208-466-5359
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13346887-9923122300000X
IDD-5558122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist