Provider Demographics
NPI:1346544178
Name:MARCUS K. JACKSON, DDS, A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:MARCUS K. JACKSON, DDS, A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:504-466-2392
Mailing Address - Street 1:8847 VETERANS MEMORIAL BLVD STE 8
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70003-7707
Mailing Address - Country:US
Mailing Address - Phone:504-466-2392
Mailing Address - Fax:504-466-2399
Practice Address - Street 1:8847 VETERANS MEMORIAL BLVD STE 8
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70003-7707
Practice Address - Country:US
Practice Address - Phone:504-466-2392
Practice Address - Fax:504-466-2399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-09
Last Update Date:2011-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty