Provider Demographics
NPI:1417006594
Name:JACKSON, WILLIAM KENNETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:KENNETH
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11411 N CENTRAL EXPY STE K
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-6606
Mailing Address - Country:US
Mailing Address - Phone:214-739-5824
Mailing Address - Fax:214-739-5073
Practice Address - Street 1:11411 N CENTRAL EXPY STE K
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-6606
Practice Address - Country:US
Practice Address - Phone:214-739-5824
Practice Address - Fax:214-739-5073
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX94411223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDO9441Medicare ID - Type Unspecified