Provider Demographics
NPI:1578707204
Name:JACKSON, ANDREA DENISE (DDS, MS)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:ANDREA
Other - Middle Name:D
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:6912 WADE AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2743
Mailing Address - Country:US
Mailing Address - Phone:301-868-3317
Mailing Address - Fax:
Practice Address - Street 1:6912 WADE AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2743
Practice Address - Country:US
Practice Address - Phone:301-868-3317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDN40771223P0700X
MD081111223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics