Basic Information
Provider Information
NPI: 1003296823
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JENKINS
FirstName: JORDAN
MiddleName: MICHAEL
NamePrefix:  
NameSuffix:  
Credential: D.D.S.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4700 LAS VEGAS BLVD N
Address2:  
City: NELLIS AFB
State: NV
PostalCode: 891916600
CountryCode: US
TelephoneNumber: 7026532600
FaxNumber:  
Practice Location
Address1: 4700 LAS VEGAS BLVD N
Address2:  
City: NELLIS AFB
State: NV
PostalCode: 891916600
CountryCode: US
TelephoneNumber: 7026532600
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/06/2015
LastUpdateDate: 08/19/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X12012319AINY Dental ProvidersDentistGeneral Practice
1223G0001XDN 21241FLN Dental ProvidersDentistGeneral Practice

No ID Information.


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