Healthcare Provider Details

I. General information

NPI: 1598373581
Provider Name (Legal Business Name): JORDAN BRUMMOND DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4204 BOULDER RIDGE RD STE 140
BISMARCK ND
58503-6162
US

IV. Provider business mailing address

4204 BOULDER RIDGE RD STE 140
BISMARCK ND
58503-6162
US

V. Phone/Fax

Practice location:
  • Phone: 701-751-7300
  • Fax: 701-250-0557
Mailing address:
  • Phone: 701-751-7300
  • Fax: 701-250-0557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2412
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: