Provider Demographics
NPI:1790089860
Name:JACKSON, DAVID CRESTON (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CRESTON
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 1:900 SE OCEAN BLVD STE 110B
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-3503
Mailing Address - Country:US
Mailing Address - Phone:772-247-2407
Mailing Address - Fax:
Practice Address - Street 1:900 SE OCEAN BLVD STE 110B
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3503
Practice Address - Country:US
Practice Address - Phone:772-247-2407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2017-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19084122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist