Provider Demographics
NPI:1790963916
Name:JACKSON, PHILIP RODNEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:RODNEY
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 1:857 SHORE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-8365
Mailing Address - Country:US
Mailing Address - Phone:803-609-5216
Mailing Address - Fax:
Practice Address - Street 1:857 SHORE VIEW DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-8365
Practice Address - Country:US
Practice Address - Phone:803-609-5216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2416122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist