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General NPI Number Information
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NPI Number | 1447738778
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Entity Type | Individual
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Provider Name | JORDAN SIMON DMD
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Gender | Female
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Dates
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Enumeration Date | 07/30/2018
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Last Update Date | 07/30/2018
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Provider Practice Location Address
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Address Line | 210 CARVERTON RD
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City | TRUCKSVILLE
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State | PA
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Zip | 18708-1745
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Country | US
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Telephone | 570-696-1105
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Fax |
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Provider Business Mailing Address
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Address Line | 1982 W 8TH ST
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City | WEST WYOMING
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State | PA
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Zip | 18644-9434
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Country | US
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Telephone | 570-466-2705
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DS041897
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License Number State | PA
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