Provider Demographics
NPI:1194854901
Name:JACKSON, ARLITA D (DMD)
Entity Type:Individual
Prefix:DR
First Name:ARLITA
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1790 MULKEY RD
Mailing Address - Street 2:STE4
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1122
Mailing Address - Country:US
Mailing Address - Phone:770-739-4400
Mailing Address - Fax:770-739-9077
Practice Address - Street 1:1790 MULKEY RD
Practice Address - Street 2:BLDG 4
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1103
Practice Address - Country:US
Practice Address - Phone:770-739-4400
Practice Address - Fax:770-739-9077
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN110041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00480213BMedicaid