Provider Demographics
NPI:1912321522
Name:JORDAN, DIVINIA (DMD)
Entity Type:Individual
Prefix:
First Name:DIVINIA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-4334
Mailing Address - Country:US
Mailing Address - Phone:516-565-6565
Mailing Address - Fax:516-565-3391
Practice Address - Street 1:639 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010-4334
Practice Address - Country:US
Practice Address - Phone:516-565-6565
Practice Address - Fax:516-565-3391
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03988811223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics