Healthcare Provider Details

I. General information

NPI: 1720904485
Provider Name (Legal Business Name): JORDAN MUNAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 PAUL JONES ST
GREAT LAKES IL
60088-2834
US

IV. Provider business mailing address

2487 CANYON CREEK RD
ESCONDIDO CA
92025-7462
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-2430
  • Fax:
Mailing address:
  • Phone: 858-444-7306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14295901-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: