Provider Demographics
NPI:1346850849
Name:REDDICK, JACKSON STEVEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:STEVEN
Last Name:REDDICK
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 1:440 S BUCKMOORE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-2700
Mailing Address - Country:US
Mailing Address - Phone:863-676-6507
Mailing Address - Fax:
Practice Address - Street 1:440 S BUCKMOORE RD
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-2700
Practice Address - Country:US
Practice Address - Phone:863-676-6507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-09
Last Update Date:2020-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25003122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist