Provider Demographics
NPI:1134552771
Name:JACKSON, ROSS (DDS)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
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 1:5005 GALLERIA
Mailing Address - Street 2:# 3216
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-5331
Mailing Address - Country:US
Mailing Address - Phone:972-658-3048
Mailing Address - Fax:
Practice Address - Street 1:5005 GALLERIA
Practice Address - Street 2:# 3216
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-5331
Practice Address - Country:US
Practice Address - Phone:972-658-3048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29058122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist