Healthcare Provider Details

I. General information

NPI: 1275850067
Provider Name (Legal Business Name): KEVIN R. JORDAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 SCOTT ST.
OLIVE HILL KY
41164
US

IV. Provider business mailing address

154 SCOTT ST.
OLIVE HILL KY
41164
US

V. Phone/Fax

Practice location:
  • Phone: 606-286-4121
  • Fax:
Mailing address:
  • Phone: 606-286-4142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberKY6868
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: