Healthcare Provider Details

I. General information

NPI: 1912832254
Provider Name (Legal Business Name): JORDAN ANDRADE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4171 CRESCENT DR STE 102
SAINT LOUIS MO
63129-3645
US

IV. Provider business mailing address

550 S CLAY AVE APT 2A
KIRKWOOD MO
63122-5964
US

V. Phone/Fax

Practice location:
  • Phone: 314-200-3880
  • Fax:
Mailing address:
  • Phone: 480-285-9973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2025032488
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: