Provider Demographics
NPI:1548970189
Name:BOONE, JORDAN BROUGHTON (DMD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:BROUGHTON
Last Name:BOONE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:OLIVIA
Other - Last Name:BROUGHTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:29138 S REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-3146
Mailing Address - Country:US
Mailing Address - Phone:601-620-9111
Mailing Address - Fax:
Practice Address - Street 1:140 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-5100
Practice Address - Country:US
Practice Address - Phone:225-800-4495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA73901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice