=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851527550
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN RISINGER D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2009
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 S. PALESTINE ST.
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-675-9118
-----------------------------------------------------
Fax | 903-677-3156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 S. PALESTINE ST.
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-675-9118
-----------------------------------------------------
Fax | 903-677-3156
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0024710
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------