Provider Demographics
NPI:1750331773
Name:JACKSON, DAVID EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:EDWARD
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 1:4327 HIDDEN QUAIL CIR
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3600
Mailing Address - Country:US
Mailing Address - Phone:801-278-9898
Mailing Address - Fax:801-571-8285
Practice Address - Street 1:870 E 9400 S
Practice Address - Street 2:#110
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3666
Practice Address - Country:US
Practice Address - Phone:801-571-8391
Practice Address - Fax:801-571-8285
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT138455-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist