Provider Demographics
NPI:1851556203
Name:JACKSON, SAMUEL S III (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:S
Last Name:JACKSON
Suffix:III
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 1:296-WHITEBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209
Mailing Address - Country:US
Mailing Address - Phone:615-352-9595
Mailing Address - Fax:615-383-4873
Practice Address - Street 1:296 WHITE BRIDGE PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-3226
Practice Address - Country:US
Practice Address - Phone:615-352-9595
Practice Address - Fax:615-383-4873
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS74191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice