Healthcare Provider Details

I. General information

NPI: 1487725727
Provider Name (Legal Business Name): ROBERT DALSON JORDAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S NORTHSHORE DR SUITE 404
KNOXVILLE TN
37919-4939
US

IV. Provider business mailing address

109 S NORTHSHORE DR SUITE 404
KNOXVILLE TN
37919-4939
US

V. Phone/Fax

Practice location:
  • Phone: 865-588-9589
  • Fax: 865-588-9865
Mailing address:
  • Phone: 865-588-9589
  • Fax: 865-588-9865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDS0000004461
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: