Healthcare Provider Details

I. General information

NPI: 1447473939
Provider Name (Legal Business Name): KEVIN R JORDAN DMD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 SCOTT ST
OLIVE HILL KY
41164
US

IV. Provider business mailing address

PO BOX 562
OLIVE HILL KY
41164
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6868
License Number StateKY

VIII. Authorized Official

Name: MR. KEVIN R JORDAN
Title or Position: OWNER
Credential: DMD
Phone: 606-286-4121