MEDICARE: DIVINIA JORDAN DMD

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	0398881	NY

General Provider Information

NPI Number	:	1912321522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIVINIA JORDAN DMD

Provider Business Mailing Address
First Line	:	639 HEMPSTEAD TPKE
Second Line	:
City	:	FRANKLIN SQUARE
State	:	NY
Zip	:	11010-4334
Country	:	US
Telephone Number	:	516-565-6565
Fax Number	:	516-565-3391

Provider Business Practice Location Address
First Line	:	639 HEMPSTEAD TPKE
Second Line	:
City	:	FRANKLIN SQUARE
State	:	NY
Zip	:	11010-4334
Country	:	US
Telephone Number	:	516-565-6565
Fax Number	:	516-565-3391

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

Provider Enumeration Date	:	02/18/2014
Last Update Date	:	02/18/2014

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