Provider Demographics
NPI:1710066998
Name:JACKSON, MICHAEL WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
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:PO BOX 825
Mailing Address - Street 2:
Mailing Address - City:SPINDALE
Mailing Address - State:NC
Mailing Address - Zip Code:28160-0825
Mailing Address - Country:US
Mailing Address - Phone:828-287-7592
Mailing Address - Fax:828-288-1293
Practice Address - Street 1:837 THUNDER RD
Practice Address - Street 2:
Practice Address - City:SPINDALE
Practice Address - State:NC
Practice Address - Zip Code:28160-1152
Practice Address - Country:US
Practice Address - Phone:828-287-7592
Practice Address - Fax:828-288-1293
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC55011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8994741Medicaid