Provider Demographics
NPI:1629789722
Name:DR BRANDON JACKSON PEDIATRIC DENTAL PLLC
Entity Type:Organization
Organization Name:DR BRANDON JACKSON PEDIATRIC DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:JOSHUA
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-626-3507
Mailing Address - Street 1:70 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1748
Mailing Address - Country:US
Mailing Address - Phone:917-626-3507
Mailing Address - Fax:
Practice Address - Street 1:821 CLOVE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-2839
Practice Address - Country:US
Practice Address - Phone:718-448-0976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty