Provider Demographics
NPI:1962481887
Name:JACKSON, MATTHEW DV (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DV
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 1:9319 E HARRY
Mailing Address - Street 2:#126
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207
Mailing Address - Country:US
Mailing Address - Phone:316-683-7081
Mailing Address - Fax:316-683-8149
Practice Address - Street 1:9319 E HARRY
Practice Address - Street 2:#126
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207
Practice Address - Country:US
Practice Address - Phone:316-683-7081
Practice Address - Fax:316-683-8149
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS71311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS059792OtherBCBS OF KS
976141OtherUNITED CONCORDIA