Provider Demographics
NPI:1285848309
Name:JACKSON, CARL DENNIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:DENNIS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 WOODLARK LN
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDDLE
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5706
Mailing Address - Country:US
Mailing Address - Phone:610-358-0369
Mailing Address - Fax:
Practice Address - Street 1:3200 CONCORD RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ASTON
Practice Address - State:PA
Practice Address - Zip Code:19014-1931
Practice Address - Country:US
Practice Address - Phone:610-872-7461
Practice Address - Fax:610-494-7559
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS018783L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist