Provider Demographics
NPI:1538253703
Name:JORGENSON, NATHAN CRAIG (DDS)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:CRAIG
Last Name:JORGENSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 SOUTH STATE STREET
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031
Mailing Address - Country:US
Mailing Address - Phone:507-235-9632
Mailing Address - Fax:507-235-5006
Practice Address - Street 1:717 SOUTH STATE STREET
Practice Address - Street 2:SUITE 600
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031
Practice Address - Country:US
Practice Address - Phone:507-235-9632
Practice Address - Fax:507-235-5006
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN88711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice