Provider Demographics
NPI:1083630248
Name:JACKMAN FAMILY DENTISTRY
Entity Type:Organization
Organization Name:JACKMAN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:BAIRSTOW
Authorized Official - Last Name:JACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-451-2982
Mailing Address - Street 1:501B NUT TREE CT
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687
Mailing Address - Country:US
Mailing Address - Phone:707-451-2982
Mailing Address - Fax:707-451-0391
Practice Address - Street 1:501B NUT TREE CT
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687
Practice Address - Country:US
Practice Address - Phone:707-451-2982
Practice Address - Fax:707-451-0391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33203122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty