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General NPI Number Information
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NPI Number | 1194679704
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Entity Type | Organization
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Legal Business Name | WISDOM TOOTH PLLC
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Dates
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Enumeration Date | 02/23/2026
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Last Update Date | 02/23/2026
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Provider Practice Location Address
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Address Line | 5675 26TH AVE S STE 116
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City | FARGO
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State | ND
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Zip | 58104-8599
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Country | US
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Telephone | 701-699-6966
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Fax | 701-929-5441
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Provider Business Mailing Address
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Address Line | 5675 26TH AVE S STE 116
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City | FARGO
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State | ND
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Zip | 58104-8599
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Country | US
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Telephone | 701-699-6966
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Fax | 701-929-5441
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Authorized Official
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Title or Position | ORAL SURGEON
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Name | CODY JOHN JORDAN
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Credential | DDS
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Telephone | 701-699-6966
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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