Provider Demographics
NPI:1710546437
Name:KYLE R. JACKSON, DDS, LLC
Entity Type:Organization
Organization Name:KYLE R. JACKSON, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-586-7729
Mailing Address - Street 1:273 REGENCY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4221
Mailing Address - Country:US
Mailing Address - Phone:937-586-7729
Mailing Address - Fax:937-660-4450
Practice Address - Street 1:4090 INDIAN RIPPLE RD UNIT 102
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45440-3253
Practice Address - Country:US
Practice Address - Phone:937-586-7729
Practice Address - Fax:937-490-9904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty