Provider Demographics
NPI:1285072975
Name:BOWER, JORDAN SHEA (DMD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:SHEA
Last Name:BOWER
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 1:350 N CLARK ST FL 6
Mailing Address - Street 2:C/O JULIETTE BOYCE
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1575 N 52ND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131
Practice Address - Country:US
Practice Address - Phone:717-433-6714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS0395861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program