Provider Demographics
NPI:1548738636
Name:JACKSON SMILE STUDIO - SDA LLC
Entity Type:Organization
Organization Name:JACKSON SMILE STUDIO - SDA LLC
Other - Org Name:JACKSON SMILE STUDIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNI
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMLINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-678-9999
Mailing Address - Street 1:225 TOWNPARK DR NW STE 100
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5885
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3790 FERNANDINA RD STE 201
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-3864
Practice Address - Country:US
Practice Address - Phone:803-678-9999
Practice Address - Fax:803-750-0021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-06
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty