Provider Demographics
NPI:1962511659
Name:CYNTHIA L JACKSON DDS MS INC
Entity Type:Organization
Organization Name:CYNTHIA L JACKSON DDS MS INC
Other - Org Name:ALPINE ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:619-445-8883
Mailing Address - Street 1:1620 ALPINE BLVD
Mailing Address - Street 2:STE 212
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-1105
Mailing Address - Country:US
Mailing Address - Phone:619-445-8883
Mailing Address - Fax:619-445-8890
Practice Address - Street 1:1620 ALPINE BLVD
Practice Address - Street 2:STE 212
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-1105
Practice Address - Country:US
Practice Address - Phone:619-445-8883
Practice Address - Fax:619-445-8890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA370341223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty