Provider Demographics
NPI:1689762569
Name:RICHARD F. JACKSON, DDS, GREGORY HEISE, DDS, AND CRAIG ALPHA, DDS
Entity Type:Organization
Organization Name:RICHARD F. JACKSON, DDS, GREGORY HEISE, DDS, AND CRAIG ALPHA, DDS
Other - Org Name:RICHARD F. JACKSON, DDS, GREGORY HEISE, DDS, AND CRAIG ALPHA, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-961-0570
Mailing Address - Street 1:2525 K ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5114
Mailing Address - Country:US
Mailing Address - Phone:916-442-1882
Mailing Address - Fax:091-644-2303
Practice Address - Street 1:2525 K ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5114
Practice Address - Country:US
Practice Address - Phone:916-442-1882
Practice Address - Fax:091-644-2303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA244651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT42816Medicare ID - Type UnspecifiedMEDICARE
CAU44323Medicare ID - Type UnspecifiedMEDICARE