Provider Demographics
NPI:1306400353
Name:BRIAN E JACKSON DDS LLC
Entity Type:Organization
Organization Name:BRIAN E JACKSON DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:440-944-7775
Mailing Address - Street 1:2775 BISHOP RD STE C
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44092-2683
Mailing Address - Country:US
Mailing Address - Phone:440-944-7775
Mailing Address - Fax:440-944-7887
Practice Address - Street 1:2775 BISHOP RD STE C
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44092-2683
Practice Address - Country:US
Practice Address - Phone:440-944-7775
Practice Address - Fax:440-944-7887
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIAN E JACKSON DDS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies