Provider Demographics
NPI:1629165170
Name:JACKSON, DAVID MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
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 1:3550 S 5600 W
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-2734
Mailing Address - Country:US
Mailing Address - Phone:801-966-3166
Mailing Address - Fax:801-966-3179
Practice Address - Street 1:3550 S 5600 W
Practice Address - Street 2:SUITE 3
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2776
Practice Address - Country:US
Practice Address - Phone:801-966-3166
Practice Address - Fax:801-966-3179
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT51380621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice