Provider Demographics
NPI:1184822397
Name:JACKSON, SANJIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SANJIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 BELCHER ROAD
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698
Mailing Address - Country:US
Mailing Address - Phone:727-738-8845
Mailing Address - Fax:727-738-1466
Practice Address - Street 1:1044 BELCHER ROAD
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698
Practice Address - Country:US
Practice Address - Phone:727-738-8845
Practice Address - Fax:727-738-1466
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18059122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist