Provider Demographics
NPI:1710461520
Name:A M JACKSON & ASSOCIATES DDS MS PLLC
Entity Type:Organization
Organization Name:A M JACKSON & ASSOCIATES DDS MS PLLC
Other - Org Name:UNIVERSITY ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATI
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDISI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-549-1926
Mailing Address - Street 1:8430 UNIVERSITY EXEC PARK DR STE 605
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1353
Mailing Address - Country:US
Mailing Address - Phone:704-549-1926
Mailing Address - Fax:
Practice Address - Street 1:8430 UNIVERSITY EXEC PARK DR STE 605
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-1353
Practice Address - Country:US
Practice Address - Phone:704-549-1926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty