Provider Demographics
NPI:1588647911
Name:JACKSON, MATTHEW J (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:243 CHARLES STREET
Practice Address - Street 2:MASS EYE AND EAR INFIRMARY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-573-4306
Practice Address - Fax:617-659-4917
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA11607204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0264822Medicaid
MA40346OtherHARVARD PILGRIM HMO
MA757863OtherTUFTS HEALTH HMO
MA40346OtherHARVARD PILGRIM HMO
MAX04571Medicare ID - Type Unspecified