Provider Demographics
NPI:1639783137
Name:BRUCE A. JACKSON II, DDS, PLC
Entity Type:Organization
Organization Name:BRUCE A. JACKSON II, DDS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:II
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-363-8707
Mailing Address - Street 1:4829 E BELTLINE AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9747
Mailing Address - Country:US
Mailing Address - Phone:616-363-8707
Mailing Address - Fax:
Practice Address - Street 1:4829 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9747
Practice Address - Country:US
Practice Address - Phone:616-363-8707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental