Provider Demographics
NPI:1841396637
Name:JACKSON AND MOORE PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JACKSON AND MOORE PROFESSIONAL CORPORATION
Other - Org Name:HUB PLAZA DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:TANISHA
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-796-6700
Mailing Address - Street 1:2860 MICHELLE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1009
Mailing Address - Country:US
Mailing Address - Phone:714-508-3600
Mailing Address - Fax:714-368-2092
Practice Address - Street 1:1047 HARRIMAN PL
Practice Address - Street 2:STE. B
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-4203
Practice Address - Country:US
Practice Address - Phone:909-796-6700
Practice Address - Fax:909-796-6779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty