Provider Demographics
NPI:1558456772
Name:JACKSON, T. RYAN (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:T.
Middle Name:RYAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 N. MADISON AVE.
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142
Mailing Address - Country:US
Mailing Address - Phone:317-887-3180
Mailing Address - Fax:317-882-2718
Practice Address - Street 1:45 N. MADISON AVE.
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142
Practice Address - Country:US
Practice Address - Phone:317-887-3180
Practice Address - Fax:317-882-2718
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120097681223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics