Provider Demographics
NPI:1467688564
Name:JACKSON, PAUL S (DMD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:S
Last Name:JACKSON
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 1:4237 CUMBERLAND RD
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2737
Mailing Address - Country:US
Mailing Address - Phone:801-671-6228
Mailing Address - Fax:
Practice Address - Street 1:26 SOUTH 200 EAST
Practice Address - Street 2:SUITE 5900
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112
Practice Address - Country:US
Practice Address - Phone:801-585-6485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program