Provider Demographics
NPI:1104479989
Name:NICKEL, JORDAN PATRICK (DMD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:PATRICK
Last Name:NICKEL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3206 N DINUBA BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-8730
Mailing Address - Country:US
Mailing Address - Phone:559-334-2013
Mailing Address - Fax:
Practice Address - Street 1:3206 N DINUBA BLVD STE F
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-8730
Practice Address - Country:US
Practice Address - Phone:559-334-2013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104023122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty