Provider Demographics
NPI:1598384935
Name:JACKSON, CYNTHIA (DDS MS)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 ANDERSON RD
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-1504
Mailing Address - Country:US
Mailing Address - Phone:619-249-0818
Mailing Address - Fax:
Practice Address - Street 1:1620 ALPINE BLVD STE 212
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-1105
Practice Address - Country:US
Practice Address - Phone:619-445-8883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA370341223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics