Provider Demographics
NPI:1497915086
Name:JACKSON, WILLIAM TRAVIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:TRAVIS
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 1:402 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-2458
Mailing Address - Country:US
Mailing Address - Phone:417-667-3006
Mailing Address - Fax:
Practice Address - Street 1:402 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-2458
Practice Address - Country:US
Practice Address - Phone:417-667-3006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080155221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice