Provider Demographics
NPI:1659679389
Name:JACKSON, LEE M (RDH)
Entity Type:Individual
Prefix:MS
First Name:LEE
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19842 E 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80249-7351
Mailing Address - Country:US
Mailing Address - Phone:720-374-0444
Mailing Address - Fax:
Practice Address - Street 1:3551 CHAMBERS RD
Practice Address - Street 2:SUITE A-D
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-1330
Practice Address - Country:US
Practice Address - Phone:303-375-0649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO904413124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist