Provider Demographics
NPI:1134289713
Name:JACKSON, PHIL D (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHIL
Middle Name:D
Last Name:JACKSON
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 1:427 N DAVIS
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482
Mailing Address - Country:US
Mailing Address - Phone:903-885-7925
Mailing Address - Fax:903-885-8794
Practice Address - Street 1:427 N DAVIS
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482
Practice Address - Country:US
Practice Address - Phone:903-885-7925
Practice Address - Fax:903-885-8794
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16061122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist