Basic Information
Provider Information
NPI: 1033558119
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JUAREZ
FirstName: JORDAN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 34703
Address2:  
City: SEATTLE
State: WA
PostalCode: 981241703
CountryCode: US
TelephoneNumber: 2067623263
FaxNumber: 2067636574
Practice Location
Address1: 8915 14TH AVE S
Address2:  
City: SEATTLE
State: WA
PostalCode: 981084813
CountryCode: US
TelephoneNumber: 2067623263
FaxNumber: 2067636574
Other Information
ProviderEnumerationDate: 06/21/2013
LastUpdateDate: 07/17/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000XDE60406335WAY Dental ProvidersDentist 

No ID Information.


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