Provider Demographics
NPI:1710959218
Name:JACKSON, ELI O (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELI
Middle Name:O
Last Name:JACKSON
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 1:727 U.S. 31 W BY PASS
Mailing Address - Street 2:SUITE 102B
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-4999
Mailing Address - Country:US
Mailing Address - Phone:270-781-2952
Mailing Address - Fax:270-793-0977
Practice Address - Street 1:727 U.S. 31 W BY PASS
Practice Address - Street 2:SUITE 102B
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-4999
Practice Address - Country:US
Practice Address - Phone:270-781-2952
Practice Address - Fax:270-793-0977
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY54501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice