Provider Demographics
NPI:1023805181
Name:ALICIA RENEE JACKSON, DDS PC
Entity type:Organization
Organization Name:ALICIA RENEE JACKSON, DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-747-6574
Mailing Address - Street 1:245 5TH AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-8728
Mailing Address - Country:US
Mailing Address - Phone:800-338-3131
Mailing Address - Fax:
Practice Address - Street 1:245 5TH AVE FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-8728
Practice Address - Country:US
Practice Address - Phone:800-338-3131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty