Provider Demographics
NPI:1811598493
Name:CLARK AND JACKSON PD, LLC
Entity Type:Organization
Organization Name:CLARK AND JACKSON PD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-548-2333
Mailing Address - Street 1:1690 HIGHWAY 160 W STE A
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8024
Mailing Address - Country:US
Mailing Address - Phone:803-548-2333
Mailing Address - Fax:803-324-4128
Practice Address - Street 1:1690 HIGHWAY 160 W STE A
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8024
Practice Address - Country:US
Practice Address - Phone:803-548-2333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-02
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty