Provider Demographics
NPI:1689101602
Name:JACKSON, NATHANIEL JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:JOSEPH
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 1:36 MEADOW CIR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45056-1585
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:322 N ELM ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:OH
Practice Address - Zip Code:45056-1123
Practice Address - Country:US
Practice Address - Phone:513-523-6267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0251001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice