Provider Demographics
NPI:1689993545
Name:DENTAL EXPRESS-MIDDLEBURG HEIGHTS, BRIAN A JACKSON DDS LLC
Entity Type:Organization
Organization Name:DENTAL EXPRESS-MIDDLEBURG HEIGHTS, BRIAN A JACKSON DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-533-3400
Mailing Address - Street 1:3800 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9029
Mailing Address - Country:US
Mailing Address - Phone:330-533-3400
Mailing Address - Fax:330-533-2700
Practice Address - Street 1:7043 PEARL RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-4973
Practice Address - Country:US
Practice Address - Phone:440-845-7900
Practice Address - Fax:440-845-7969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH19620122300000X
OH022150122300000X
OH14383122300000X
OH30-023233122300000X
OH30-016841122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty