Provider Demographics
NPI:1780106393
Name:KOFOED, JORDAN VAL (DDS)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:VAL
Last Name:KOFOED
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:PO BOX 576
Mailing Address - Street 2:
Mailing Address - City:DOVE CREEK
Mailing Address - State:CO
Mailing Address - Zip Code:81324-0576
Mailing Address - Country:US
Mailing Address - Phone:970-677-2291
Mailing Address - Fax:
Practice Address - Street 1:495 WEST 4TH STREET
Practice Address - Street 2:
Practice Address - City:DOVE CREEK
Practice Address - State:CO
Practice Address - Zip Code:81324
Practice Address - Country:US
Practice Address - Phone:970-677-2291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00203268122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist