Provider Demographics
NPI:1144679507
Name:JACKSON PEDIATRIC DENTISTRY LLC
Entity type:Organization
Organization Name:JACKSON PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:919-412-4199
Mailing Address - Street 1:1686 HIGHWAY 160 W
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8024
Mailing Address - Country:US
Mailing Address - Phone:803-548-2333
Mailing Address - Fax:803-548-2703
Practice Address - Street 1:1236 EBENEZER RD
Practice Address - Street 2:SUITE 110
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3390
Practice Address - Country:US
Practice Address - Phone:803-324-7540
Practice Address - Fax:803-324-4128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty