MEDICARE: AARON JORDAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	061533	NY

General Provider Information

NPI Number	:	1821651068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AARON JORDAN

Provider Business Mailing Address
First Line	:	177 SHERWOOD PL
Second Line	:
City	:	ENGLEWOOD
State	:	NJ
Zip	:	07631-3610
Country	:	US
Telephone Number	:	917-607-0669
Fax Number	:

Provider Business Practice Location Address
First Line	:	1840 COMMERCE ST
Second Line	:
City	:	YORKTOWN HEIGHTS
State	:	NY
Zip	:	10598-4400
Country	:	US
Telephone Number	:	914-962-7588
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2019
Last Update Date	:	12/02/2020

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