Provider Demographics
NPI:1083272090
Name:BOONE, JACKSON PRICE
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:PRICE
Last Name:BOONE
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 1:213 CHURCH ST NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-4763
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-4763
Practice Address - Country:US
Practice Address - Phone:704-782-1012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC113871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice