Healthcare Provider Details

I. General information

NPI: 1497826960
Provider Name (Legal Business Name): KALISHA JORDAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 BULIFANTS BLVD SUITE B
WILLIAMSBURG VA
23188-5717
US

IV. Provider business mailing address

105 BULIFANTS BLVD SUITE B
WILLIAMSBURG VA
23188
US

V. Phone/Fax

Practice location:
  • Phone: 757-903-2577
  • Fax: 757-903-2866
Mailing address:
  • Phone: 757-903-2577
  • Fax: 757-903-2286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401411472
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: