Provider Demographics
NPI:1740902006
Name:JORDAN, MICHAEL EUGENE JR (DMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EUGENE
Last Name:JORDAN
Suffix:JR
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 1:5081 CITY STATION DR APT 201
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-7080
Mailing Address - Country:US
Mailing Address - Phone:919-333-2258
Mailing Address - Fax:
Practice Address - Street 1:5550 HIGHWAY 153 STE 100
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4991
Practice Address - Country:US
Practice Address - Phone:423-875-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12025122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist