MEDICARE: DR. JORDAN BRUMMOND DDS

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	122300000X	Dentist	2412	ND

General Provider Information

NPI Number	:	1598373581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORDAN BRUMMOND DDS

Provider Business Mailing Address
First Line	:	4204 BOULDER RIDGE RD STE 140
Second Line	:
City	:	BISMARCK
State	:	ND
Zip	:	58503-6162
Country	:	US
Telephone Number	:	701-751-7300
Fax Number	:	701-250-0557

Provider Business Practice Location Address
First Line	:	4204 BOULDER RIDGE RD STE 140
Second Line	:
City	:	BISMARCK
State	:	ND
Zip	:	58503-6162
Country	:	US
Telephone Number	:	701-751-7300
Fax Number	:	701-250-0557

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

Provider Enumeration Date	:	07/16/2020
Last Update Date	:	07/16/2020

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