Healthcare Provider Details

I. General information

NPI: 1043847874
Provider Name (Legal Business Name): CODY JORDAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 01/27/2026
Certification Date: 01/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5675 26TH AVE S STE 116
FARGO ND
58104-8599
US

IV. Provider business mailing address

5675 26TH AVE S STE 116
FARGO ND
58104-8599
US

V. Phone/Fax

Practice location:
  • Phone: 701-699-6966
  • Fax: 701-929-5441
Mailing address:
  • Phone: 701-699-6966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS221
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2518
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: