Provider Demographics
NPI:1144394545
Name:JACKSON DENTAL PROF. LLC
Entity Type:Organization
Organization Name:JACKSON DENTAL PROF. LLC
Other - Org Name:JOHN H JACKSON DDS PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:605-892-6347
Mailing Address - Street 1:503 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BELLE FOURCHE
Mailing Address - State:SD
Mailing Address - Zip Code:57717
Mailing Address - Country:US
Mailing Address - Phone:605-892-6347
Mailing Address - Fax:605-892-9027
Practice Address - Street 1:503 JACKSON ST
Practice Address - Street 2:
Practice Address - City:BELLE FOURCHE
Practice Address - State:SD
Practice Address - Zip Code:57717
Practice Address - Country:US
Practice Address - Phone:605-892-6347
Practice Address - Fax:605-892-9027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM525122300000X
SDD0633122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty