Provider Demographics
NPI:1275517781
Name:JACKSON, BENITA S (DDS)
Entity Type:Individual
Prefix:
First Name:BENITA
Middle Name:S
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 1:617 WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37206-4211
Mailing Address - Country:US
Mailing Address - Phone:615-299-5666
Mailing Address - Fax:
Practice Address - Street 1:617 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37206-4211
Practice Address - Country:US
Practice Address - Phone:615-256-2321
Practice Address - Fax:615-256-2329
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS71421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice