Provider Demographics
NPI:1518108190
Name:RALPH L. JACKSON, DDS, PC
Entity Type:Organization
Organization Name:RALPH L. JACKSON, DDS, PC
Other - Org Name:CORNELIA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:706-778-8645
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-12
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN009940261QD0000X
GADN014968261QD0000X
GADN013723261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental