Provider Demographics
NPI:1659133296
Name:JACKSON, WESTON (DMD)
Entity Type:Individual
Prefix:
First Name:WESTON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 OLD BOILING SPRINGS RD STE A
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-4257
Mailing Address - Country:US
Mailing Address - Phone:864-761-0123
Mailing Address - Fax:
Practice Address - Street 1:201 OLD BOILING SPRINGS RD STE A
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-4257
Practice Address - Country:US
Practice Address - Phone:864-761-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10696122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist