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General NPI Number Information
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NPI Number | 1669043352
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Entity Type | Individual
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Provider Name | JOURDAN LYNNE KILTHAU
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Gender | Female
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Dates
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Enumeration Date | 07/05/2021
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Last Update Date | 10/02/2024
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Provider Practice Location Address
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Address Line | 9225 DOERR RD # 1220
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City | FORT BELVOIR
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State | VA
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Zip | 22060-2204
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Country | US
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Telephone | 571-231-6056
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Fax |
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Provider Business Mailing Address
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Address Line | 111 BRICKWORKS DR APT 1209
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City | CAYCE
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State | SC
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Zip | 29033-4432
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Country | US
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Telephone | 573-528-2426
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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 | 9974
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License Number State | SC
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