Provider Demographics
NPI:1831759885
Name:JORDAN DENTAL /SELF
Entity type:Organization
Organization Name:JORDAN DENTAL /SELF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-870-3967
Mailing Address - Street 1:130 W OLD HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:MERNA
Mailing Address - State:NE
Mailing Address - Zip Code:68856-5627
Mailing Address - Country:US
Mailing Address - Phone:308-870-3967
Mailing Address - Fax:
Practice Address - Street 1:130 W OLD HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:MERNA
Practice Address - State:NE
Practice Address - Zip Code:68856-5627
Practice Address - Country:US
Practice Address - Phone:308-870-3967
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental