MEDICARE: DR. JOHN ROSS JORDAN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	10689	MN

General Provider Information

NPI Number	:	1417963695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN ROSS JORDAN D.D.S.

Provider Business Mailing Address
First Line	:	24069 WOODLAND LN
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-7117
Country	:	US
Telephone Number	:	218-847-8416
Fax Number	:	218-847-5081

Provider Business Practice Location Address
First Line	:	1106 W RIVER RD
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-2723
Country	:	US
Telephone Number	:	218-846-1900
Fax Number	:	218-847-5081

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	07/08/2007

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