Provider Demographics
NPI:1265624332
Name:JACKSON, MARVIN BLANE (DDS)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:BLANE
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 1:230 N FAIRGROUNDS RD
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-4205
Mailing Address - Country:US
Mailing Address - Phone:435-637-2100
Mailing Address - Fax:435-637-5007
Practice Address - Street 1:4550 E BELL RD. ST. 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-9306
Practice Address - Country:US
Practice Address - Phone:602-485-1588
Practice Address - Fax:602-707-9740
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6605138-9921122300000X
AZD010196122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist