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General NPI Number Information
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NPI Number | 1639866213
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Entity Type | Individual
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Provider Name | SCOTT RICHARD JORDAN DMD
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Gender | Male
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Dates
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Enumeration Date | 04/24/2023
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Last Update Date | 06/23/2025
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Provider Practice Location Address
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Address Line | 201 S PARADISE AVE
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City | MIDDLETON
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State | ID
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Zip | 83644-5809
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Country | US
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Telephone | 208-585-0048
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Fax | 208-466-5359
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Provider Business Mailing Address
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Address Line | 1501 KINGS HWY
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City | SHREVEPORT
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State | LA
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Zip | 71103-4228
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Country | US
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Telephone | 318-626-0434
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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 | 13346887-9923
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D-5558
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License Number State | ID
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