Provider Demographics
NPI:1689665408
Name:JACKSON, BRIAN E (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:E
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 1:2775 BISHOP RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44092-2683
Mailing Address - Country:US
Mailing Address - Phone:440-944-7775
Mailing Address - Fax:440-944-7887
Practice Address - Street 1:2775 BISHOP RD
Practice Address - Street 2:SUITE C
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44092-2683
Practice Address - Country:US
Practice Address - Phone:440-944-7775
Practice Address - Fax:440-944-7887
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-01
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH19620332B00000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0879287Medicaid