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General NPI Number Information
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NPI Number | 1104072867
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Entity Type | Individual
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Provider Name | JORDAN THOMAS MASSON D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 08/13/2008
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Last Update Date | 08/13/2008
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Provider Practice Location Address
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Address Line | 242 MUSTANG TRL SUITE #9
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City | VIRGINIA BEACH
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State | VA
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Zip | 23452-7515
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Country | US
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Telephone | 757-340-1153
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Fax |
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Provider Business Mailing Address
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Address Line | 2533 SHIPS WATCH CT
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City | VIRGINIA BEACH
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State | VA
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Zip | 23451-1269
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Country | US
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Telephone | 248-410-0999
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 0401412245
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901019784
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License Number State | MI
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