Provider Demographics
NPI:1750449146
Name:JACKSON, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 INTERNATIONAL PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-6612
Mailing Address - Country:US
Mailing Address - Phone:972-270-6646
Mailing Address - Fax:
Practice Address - Street 1:3501 TOWNE CROSSING BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-2783
Practice Address - Country:US
Practice Address - Phone:972-270-6646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX128471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice