Healthcare Provider Details

I. General information

NPI: 1508086455
Provider Name (Legal Business Name): JORDAN DENTAL CARE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 BROADWAY ST S
JORDAN MN
55352-1557
US

IV. Provider business mailing address

224 BROADWAY ST S
JORDAN MN
55352-1557
US

V. Phone/Fax

Practice location:
  • Phone: 952-492-2021
  • Fax: 952-492-6505
Mailing address:
  • Phone: 952-492-2021
  • Fax: 952-492-6505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD11804
License Number StateMN

VIII. Authorized Official

Name: ELIZABETH M THELEMANN-ZUNIGA
Title or Position: OWNER-PRESIDENT
Credential:
Phone: 952-492-2021