MEDICARE: DR. LEANNA GWEN JORDEN DDS

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	1223G0001X	General Practice Dentistry	12580	TX

General Provider Information

NPI Number	:	1891790655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEANNA GWEN JORDEN DDS

Provider Business Mailing Address
First Line	:	5301 50TH ST
Second Line	:	STE 300
City	:	LUBBOCK
State	:	TX
Zip	:	79414-5834
Country	:	US
Telephone Number	:	806-797-7078
Fax Number	:	806-792-3739

Provider Business Practice Location Address
First Line	:	5301 50TH ST
Second Line	:	STE 300
City	:	LUBBOCK
State	:	TX
Zip	:	79414-5834
Country	:	US
Telephone Number	:	806-797-7078
Fax Number	:	806-792-3739

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

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	07/08/2007

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