Provider Demographics
NPI:1225053531
Name:JACKSON, DANA M (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 PINES RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-3403
Mailing Address - Country:US
Mailing Address - Phone:318-686-2015
Mailing Address - Fax:318-686-2018
Practice Address - Street 1:7101 PINES RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-3403
Practice Address - Country:US
Practice Address - Phone:318-686-2015
Practice Address - Fax:318-686-2018
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5769122300000X
IL019-0258791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice