Healthcare Provider Details

I. General information

NPI: 1891009346
Provider Name (Legal Business Name): EBONY JORDAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1427 MISSION ST
SOUTH PASADENA CA
91030-3213
US

IV. Provider business mailing address

1427 MISSION ST
SOUTH PASADENA CA
91030-3213
US

V. Phone/Fax

Practice location:
  • Phone: 626-403-1800
  • Fax:
Mailing address:
  • Phone: 626-669-4655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12012022A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12012022A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDDS103462
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: