Provider Demographics
NPI:1477762391
Name:JACKSON, LOIS ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LOIS
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 LAGUARDIA PL
Mailing Address - Street 2:L4
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-2001
Mailing Address - Country:US
Mailing Address - Phone:212-995-8888
Mailing Address - Fax:212-995-0131
Practice Address - Street 1:505 LAGUARDIA PL
Practice Address - Street 2:L4
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2001
Practice Address - Country:US
Practice Address - Phone:212-995-8888
Practice Address - Fax:212-995-0131
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0332231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry