Healthcare Provider Details

I. General information

NPI: 1992785752
Provider Name (Legal Business Name): BRUCE M JORDAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6120 PASEO DEL NORTE K-1
CARLSBAD CA
92011
US

IV. Provider business mailing address

PO BOX 130939
CARLSBAD CA
92013-0939
US

V. Phone/Fax

Practice location:
  • Phone: 760-438-0948
  • Fax: 760-438-7821
Mailing address:
  • Phone: 760-438-0948
  • Fax: 760-438-7821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number28010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: