Provider Demographics
NPI:1184835787
Name:JACKSON, BRETT RYAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:RYAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1868 N HILL FIELD RD
Mailing Address - Street 2:STE. 110
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-2192
Mailing Address - Country:US
Mailing Address - Phone:801-774-8198
Mailing Address - Fax:
Practice Address - Street 1:1868 N HILL FIELD RD
Practice Address - Street 2:STE. 110
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2192
Practice Address - Country:US
Practice Address - Phone:801-774-8198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6593716-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice