MEDICARE: DR. JORDAN HETTWER 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	2901601404	MI

General Provider Information

NPI Number	:	1962134320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORDAN HETTWER DDS

Provider Business Mailing Address
First Line	:	2215 9TH AVE S
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-4115
Country	:	US
Telephone Number	:	701-741-2492
Fax Number	:

Provider Business Practice Location Address
First Line	:	1003 N LAFAYETTE ST
Second Line	:
City	:	GREENVILLE
State	:	MI
Zip	:	48838-1168
Country	:	US
Telephone Number	:	616-225-9650
Fax Number	:

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

Provider Enumeration Date	:	06/25/2022
Last Update Date	:	06/25/2022

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