Provider Demographics
NPI:1235449919
Name:C. JACKSON ALLAN DDS PC
Entity Type:Organization
Organization Name:C. JACKSON ALLAN DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:ALLAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-565-7455
Mailing Address - Street 1:2414 W 7800 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-4292
Mailing Address - Country:US
Mailing Address - Phone:801-565-7455
Mailing Address - Fax:801-569-1922
Practice Address - Street 1:2414 W 7800 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-4292
Practice Address - Country:US
Practice Address - Phone:801-565-7455
Practice Address - Fax:801-569-1922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5149430122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty