Provider Demographics
NPI:1205931599
Name:JACKSON, RODNEY ALLEN (DMD)
Entity type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:ALLEN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2517 SIR BARTON WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2275
Mailing Address - Country:US
Mailing Address - Phone:859-543-2456
Mailing Address - Fax:859-543-2373
Practice Address - Street 1:2517 SIR BARTON WAY STE 200
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2275
Practice Address - Country:US
Practice Address - Phone:859-543-2456
Practice Address - Fax:859-543-2373
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY77501223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60002201Medicaid