Provider Demographics
NPI:1891987368
Name:BOOTH, JACKSON ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:ROBERT
Last Name:BOOTH
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 1:4410 E RIVERSIDE DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-4799
Mailing Address - Country:US
Mailing Address - Phone:512-739-9440
Mailing Address - Fax:512-389-9797
Practice Address - Street 1:4410 E RIVERSIDE DR
Practice Address - Street 2:SUITE 150
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-4799
Practice Address - Country:US
Practice Address - Phone:512-739-9440
Practice Address - Fax:512-389-9797
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX234961223G0001X
ORD9554122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist