Provider Demographics
NPI:1598989030
Name:JACKSON, ROBERT CHARLES II (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CHARLES
Last Name:JACKSON
Suffix:II
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:PO BOX 360
Mailing Address - Street 2:59 N MAIN ST
Mailing Address - City:EARLVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13332
Mailing Address - Country:US
Mailing Address - Phone:315-691-6502
Mailing Address - Fax:315-691-3119
Practice Address - Street 1:59 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EARLVILLE
Practice Address - State:NY
Practice Address - Zip Code:13332
Practice Address - Country:US
Practice Address - Phone:315-691-6502
Practice Address - Fax:315-691-3119
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038574122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist