Provider Demographics
NPI:1598788796
Name:JACKSON, MARK K (DDS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:K
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3556 TIMBER LANE
Mailing Address - Street 2:
Mailing Address - City:CROSS PLAINS
Mailing Address - State:WI
Mailing Address - Zip Code:53528
Mailing Address - Country:US
Mailing Address - Phone:608-798-3733
Mailing Address - Fax:608-833-1737
Practice Address - Street 1:7007 OLD SAUK ROAD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717
Practice Address - Country:US
Practice Address - Phone:608-833-2060
Practice Address - Fax:608-833-1737
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33475100Medicaid
WI79095Medicare ID - Type Unspecified
WI0002Medicare ID - Type Unspecified
WI33475100Medicaid