Provider Demographics
NPI:1699213959
Name:JACKSON, HENRY LEE JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:LEE
Last Name:JACKSON
Suffix:JR
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 1:145 CROWNE CHASE DR APT 16
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-3582
Mailing Address - Country:US
Mailing Address - Phone:631-671-1137
Mailing Address - Fax:
Practice Address - Street 1:334 E HANES MILL RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-9135
Practice Address - Country:US
Practice Address - Phone:336-450-2077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC109221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice