Basic Information
| Provider Information | |||||||||
| NPI: | 1134780125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | JACOB | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 ERIE ST SE APT 302 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554143047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188500590 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 401 RAILROAD ST W | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062584789 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2019 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 17391 | MT | Y | Dental Providers | Dentist | General Practice |
No ID Information.