Healthcare Provider Details

I. General information

NPI: 1700887189
Provider Name (Legal Business Name): JORDAN ARTHUR DEAN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 OMNI DRIVE
SENECA SC
29672-9448
US

IV. Provider business mailing address

1 INDEPENDENCE PT SUITE 212
GREENVILLE SC
29615-4545
US

V. Phone/Fax

Practice location:
  • Phone: 864-888-4222
  • Fax: 864-888-0023
Mailing address:
  • Phone: 864-797-6306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10252
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: