Provider Demographics
NPI:1922318195
Name:ALFRED M. JACKSON DDS,MS PLLC
Entity Type:Organization
Organization Name:ALFRED M. JACKSON DDS,MS PLLC
Other - Org Name:JACKSON ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:MANWUEL
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:352-256-8164
Mailing Address - Street 1:125 W. TREMONT AVE.
Mailing Address - Street 2:APT# 833
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13527 STEELECROFT PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278
Practice Address - Country:US
Practice Address - Phone:352-256-8164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC85271223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty