Provider Demographics
NPI:1639516776
Name:JACKSON, DAVID A (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
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 1:2548 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-2751
Mailing Address - Country:US
Mailing Address - Phone:816-535-8778
Mailing Address - Fax:
Practice Address - Street 1:1000 N MAIN ST STE 5
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:KS
Practice Address - Zip Code:66043-1315
Practice Address - Country:US
Practice Address - Phone:913-727-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110144521223G0001X
KS608281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice