Provider Demographics
NPI:1407120504
Name:JACKSON DENTAL
Entity Type:Organization
Organization Name:JACKSON DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:DIRK
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-667-3535
Mailing Address - Street 1:456 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-2427
Mailing Address - Country:US
Mailing Address - Phone:810-667-3535
Mailing Address - Fax:810-245-5723
Practice Address - Street 1:456 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-2427
Practice Address - Country:US
Practice Address - Phone:810-667-3535
Practice Address - Fax:810-245-5723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty