Provider Demographics
NPI:1740203496
Name:JACKSON, TRACY LESLIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LESLIE
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 1:1731 MANATEE AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208
Mailing Address - Country:US
Mailing Address - Phone:941-749-5512
Mailing Address - Fax:941-749-5826
Practice Address - Street 1:1731 MANATEE AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208
Practice Address - Country:US
Practice Address - Phone:941-749-5512
Practice Address - Fax:941-749-5826
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00132141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice