Provider Demographics
NPI:1548873292
Name:ANNIS, JORDAN JON
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:JON
Last Name:ANNIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15255 WATERTOWN PLANK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2338
Mailing Address - Country:US
Mailing Address - Phone:262-784-7770
Mailing Address - Fax:
Practice Address - Street 1:15255 WATERTOWN PLANK RD STE 100
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2338
Practice Address - Country:US
Practice Address - Phone:262-784-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002421-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist