Provider Demographics
NPI:1336496819
Name:TONJOLIQUE J. JACKSON DDS, PC
Entity Type:Organization
Organization Name:TONJOLIQUE J. JACKSON DDS, PC
Other - Org Name:SHINE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TONJOLIQUE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-293-8033
Mailing Address - Street 1:950 E BELT LINE RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-2422
Mailing Address - Country:US
Mailing Address - Phone:972-293-8033
Mailing Address - Fax:972-293-8028
Practice Address - Street 1:950 E BELT LINE RD
Practice Address - Street 2:SUITE 130
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-2422
Practice Address - Country:US
Practice Address - Phone:972-293-8033
Practice Address - Fax:972-293-8028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23084261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental