Provider Demographics
NPI:1265510457
Name:JACKSON, CARL JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 PELHAM DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1321
Mailing Address - Country:US
Mailing Address - Phone:803-661-8412
Mailing Address - Fax:803-661-8415
Practice Address - Street 1:145 PELHAM DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1321
Practice Address - Country:US
Practice Address - Phone:803-661-8412
Practice Address - Fax:803-661-8415
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010844A122300000X
SC70451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200865730AMedicaid
SCPENDINGMedicaid