Provider Demographics
NPI:1255172318
Name:JACKSON, ADRIAN JR (DMD)
Entity type:Individual
Prefix:DR
First Name:ADRIAN
Middle Name:
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 GRAYSON DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:SC
Mailing Address - Zip Code:29369-8919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 WESTVIEW BLVD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-4132
Practice Address - Country:US
Practice Address - Phone:864-515-6667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.107961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty