Provider Demographics
NPI:1760861421
Name:ROBERT C JACKSON II D.D.S. PC
Entity Type:Organization
Organization Name:ROBERT C JACKSON II D.D.S. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:II
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-691-6502
Mailing Address - Street 1:P.O. BOX 360
Mailing Address - Street 2:59 NORTH MAIN STREET
Mailing Address - City:EARLVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13332
Mailing Address - Country:US
Mailing Address - Phone:315-691-6502
Mailing Address - Fax:315-691-3119
Practice Address - Street 1:59 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:EARLVILLE
Practice Address - State:NY
Practice Address - Zip Code:13332
Practice Address - Country:US
Practice Address - Phone:315-691-6502
Practice Address - Fax:315-691-3119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038574122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00914058Medicaid