Provider Demographics
NPI:1699812644
Name:JACKSON, DAVID M (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
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 1:2 ORCHARD POINT RD
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-2002
Mailing Address - Country:US
Mailing Address - Phone:573-221-1227
Mailing Address - Fax:573-221-5564
Practice Address - Street 1:2727 SAINT MARYS AVE
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-3774
Practice Address - Country:US
Practice Address - Phone:573-221-1227
Practice Address - Fax:573-221-5564
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO134861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice