Provider Demographics
NPI:1699858001
Name:FORDHAM, JACKSON D (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:D
Last Name:FORDHAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 FAIRVIEW PARK DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2547
Mailing Address - Country:US
Mailing Address - Phone:478-272-4051
Mailing Address - Fax:478-272-3310
Practice Address - Street 1:204 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2547
Practice Address - Country:US
Practice Address - Phone:478-272-4051
Practice Address - Fax:478-272-3310
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9503122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist