Provider Demographics
NPI:1114328366
Name:JACKSON, DANA MARIE (DMD)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:MARIE
Last Name:JACKSON
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 1:6950 NE CAMPUS WAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5611
Mailing Address - Country:US
Mailing Address - Phone:618-560-8849
Mailing Address - Fax:
Practice Address - Street 1:101 S STATE HIGHWAY 125
Practice Address - Street 2:
Practice Address - City:STRAFFORD
Practice Address - State:MO
Practice Address - Zip Code:65757-8997
Practice Address - Country:US
Practice Address - Phone:417-631-4490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20230311971223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty