Provider Demographics
NPI:1467511642
Name:JACKSON, DOLPHUS CARL (DDS, PC)
Entity Type:Individual
Prefix:DR
First Name:DOLPHUS
Middle Name:CARL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3098 CAMPBELL STATION PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37174-6201
Mailing Address - Country:US
Mailing Address - Phone:615-302-8471
Mailing Address - Fax:615-302-8081
Practice Address - Street 1:3098 CAMPBELL STATION PKWY
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:TN
Practice Address - Zip Code:37174-6270
Practice Address - Country:US
Practice Address - Phone:615-302-8471
Practice Address - Fax:615-302-8081
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000080351223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4105175OtherBCBS OF TENNESSEE
TN0015802OtherASSURANT EMPLOYEE BNFTS
TN4105175OtherTENNCARE SELECT
TN281433OtherCIGNA DMO DENTAL PLAN
TN9176594OtherDORAL USA
TN3731118Medicaid
TN0015802OtherASSURANT EMPLOYEE BNFTS
TN4105175OtherTENNCARE SELECT