Healthcare Provider Details

I. General information

NPI: 1427858232
Provider Name (Legal Business Name): ETHAN E JORDAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2025
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 FLORIDA AVENUE BOX 18, ROOM 5321
NEW ORLEANS LA
70119-2799
US

IV. Provider business mailing address

PO BOX 42
FRYEBURG ME
04037-0042
US

V. Phone/Fax

Practice location:
  • Phone: 504-941-8212
  • Fax:
Mailing address:
  • Phone: 207-890-1349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7701
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: