Provider Demographics
NPI:1851430532
Name:JACKSON, BRUCE W (DDS)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 LILAC DR
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901
Mailing Address - Country:US
Mailing Address - Phone:620-624-0196
Mailing Address - Fax:620-624-2443
Practice Address - Street 1:111 LILAC DR
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901
Practice Address - Country:US
Practice Address - Phone:620-624-0196
Practice Address - Fax:620-624-2443
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5376122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS5376OtherKANSAS DENTAL BOARD