Provider Demographics
NPI:1508869231
Name:JACKSON, RALPH L (DDS)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:L
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 1:105 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CORNELIA
Mailing Address - State:GA
Mailing Address - Zip Code:30531-4366
Mailing Address - Country:US
Mailing Address - Phone:706-778-8645
Mailing Address - Fax:706-776-2650
Practice Address - Street 1:105 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CORNELIA
Practice Address - State:GA
Practice Address - Zip Code:30531-4366
Practice Address - Country:US
Practice Address - Phone:706-778-8645
Practice Address - Fax:706-776-2650
Is Sole Proprietor?:No
Enumeration Date:2005-05-26
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA0099401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice