Provider Demographics
NPI:1114368917
Name:JACKSON, SEAN (RDH)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-1968
Mailing Address - Country:US
Mailing Address - Phone:313-369-2600
Mailing Address - Fax:313-369-2477
Practice Address - Street 1:111 W 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-1968
Practice Address - Country:US
Practice Address - Phone:313-369-2600
Practice Address - Fax:313-369-2477
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902014962124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist