Provider Demographics
NPI:1780043000
Name:MIDWAY FAMILY DENTAL
Entity Type:Organization
Organization Name:MIDWAY FAMILY DENTAL
Other - Org Name:RB JACKSON, III DMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROLLIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-880-2288
Mailing Address - Street 1:PO BOX 134
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:GA
Mailing Address - Zip Code:31320-0134
Mailing Address - Country:US
Mailing Address - Phone:912-880-2288
Mailing Address - Fax:912-880-2110
Practice Address - Street 1:1718 N COASTAL HWY
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:GA
Practice Address - Zip Code:31320-3415
Practice Address - Country:US
Practice Address - Phone:912-880-2288
Practice Address - Fax:912-880-2110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0130911223G0001X
GA0144471223G0001X
GA0145741223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty