Provider Demographics
NPI:1316237688
Name:JORDAN, SHARON SNELL (DMD)
Entity type:Individual
Prefix:DR
First Name:SHARON
Middle Name:SNELL
Last Name:JORDAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2614 CHEROKEE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-3924
Mailing Address - Country:US
Mailing Address - Phone:678-230-6929
Mailing Address - Fax:478-743-3583
Practice Address - Street 1:2614 CHEROKEE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-3924
Practice Address - Country:US
Practice Address - Phone:478-743-3583
Practice Address - Fax:478-743-8847
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2015-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0096861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00254878CMedicaid
GA00254878CMedicaid