Provider Demographics
NPI:1164920096
Name:A PLACE TO SMILE JONATHAN JACKSON DDS LLC
Entity Type:Organization
Organization Name:A PLACE TO SMILE JONATHAN JACKSON DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-489-6811
Mailing Address - Street 1:485 S MAIN ST STE 302
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-2290
Mailing Address - Country:US
Mailing Address - Phone:801-489-6811
Mailing Address - Fax:801-489-6840
Practice Address - Street 1:485 S MAIN ST STE 302
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-2290
Practice Address - Country:US
Practice Address - Phone:801-489-6811
Practice Address - Fax:801-489-6840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7025515261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental