Provider Demographics
NPI:1588002620
Name:JACKSON DENTAL, P.A.
Entity Type:Organization
Organization Name:JACKSON DENTAL, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:352-871-2577
Mailing Address - Street 1:101 E KENNEDY BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5179
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 E KENNEDY BLVD
Practice Address - Street 2:STE 300
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-5179
Practice Address - Country:US
Practice Address - Phone:352-871-2577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18870261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental