Provider Demographics
NPI:1821429531
Name:JACKSON FAMILY DENTAL,PLLC
Entity Type:Organization
Organization Name:JACKSON FAMILY DENTAL,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEADE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-868-2476
Mailing Address - Street 1:607 W DUE WEST AVE
Mailing Address - Street 2:SUIT 110
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-4431
Mailing Address - Country:US
Mailing Address - Phone:615-868-2476
Mailing Address - Fax:615-868-2477
Practice Address - Street 1:607 W DUE WEST AVE
Practice Address - Street 2:SUIT 110
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-4431
Practice Address - Country:US
Practice Address - Phone:615-868-2476
Practice Address - Fax:615-868-2477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN81351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty