Provider Demographics
NPI:1588657795
Name:DARRELL JACKSON
Entity Type:Organization
Organization Name:DARRELL JACKSON
Other - Org Name:COTTONWOOD DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:GILBERT
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-589-5272
Mailing Address - Street 1:2405 MULLINS AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101
Mailing Address - Country:US
Mailing Address - Phone:719-589-5272
Mailing Address - Fax:719-589-5300
Practice Address - Street 1:2405 MULLINS AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101
Practice Address - Country:US
Practice Address - Phone:719-589-5272
Practice Address - Fax:719-589-5300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO82931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08230064Medicaid