Healthcare Provider Details

I. General information

NPI: 1477498566
Provider Name (Legal Business Name): JORDAN BLAINE LUNDEEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 NW 30TH ST
OKLAHOMA CITY OK
73112-7404
US

IV. Provider business mailing address

3000 DRAKE CREST DR
EDMOND OK
73034-0018
US

V. Phone/Fax

Practice location:
  • Phone: 405-402-4680
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8206
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: