Provider Demographics
NPI:1689192627
Name:JORDAN-GONZALEZ, MICHELLE C (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:C
Last Name:JORDAN-GONZALEZ
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 1:23250 MERCANTILE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5928
Mailing Address - Country:US
Mailing Address - Phone:216-920-9593
Mailing Address - Fax:
Practice Address - Street 1:23250 MERCANTILE RD STE 110
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5928
Practice Address - Country:US
Practice Address - Phone:216-920-9593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041470122300000X
OH300258301223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist