Provider Demographics
NPI:1841396108
Name:JACKSON, OPHELIA FAYE (DDS)
Entity Type:Individual
Prefix:DR
First Name:OPHELIA
Middle Name:FAYE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-1225
Mailing Address - Country:US
Mailing Address - Phone:516-459-4739
Mailing Address - Fax:212-206-0298
Practice Address - Street 1:429 W 24TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-1225
Practice Address - Country:US
Practice Address - Phone:516-459-4739
Practice Address - Fax:212-206-0298
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047262-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist