Provider Demographics
NPI:1003071697
Name:JACKMAN, WAYNE PAUL (DDS)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:PAUL
Last Name:JACKMAN
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 1:444 S MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266
Mailing Address - Country:US
Mailing Address - Phone:330-297-6216
Mailing Address - Fax:330-297-5803
Practice Address - Street 1:444 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:RAVENA
Practice Address - State:OH
Practice Address - Zip Code:44233
Practice Address - Country:US
Practice Address - Phone:330-297-6216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0191261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice