Provider Demographics
NPI:1629183777
Name:JACKSON, TANISHA A (DDS)
Entity Type:Individual
Prefix:DR
First Name:TANISHA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-3206
Mailing Address - Country:US
Mailing Address - Phone:909-792-7500
Mailing Address - Fax:909-792-7503
Practice Address - Street 1:2860 MICHELLE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-1009
Practice Address - Country:US
Practice Address - Phone:714-508-3600
Practice Address - Fax:714-368-2092
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA471031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice