Provider Demographics
NPI:1417666595
Name:SUSANNE P. JACKSON, DDS, PA
Entity Type:Organization
Organization Name:SUSANNE P. JACKSON, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:G
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-968-9874
Mailing Address - Street 1:77 VILCOM CENTER DR STE 180
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-1789
Mailing Address - Country:US
Mailing Address - Phone:919-968-9874
Mailing Address - Fax:919-869-1335
Practice Address - Street 1:77 VILCOM CENTER DR STE 180
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-1789
Practice Address - Country:US
Practice Address - Phone:919-968-9874
Practice Address - Fax:919-869-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty