Provider Demographics
NPI:1295955573
Name:JACKSON, DAVID PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:PAUL
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 1:3393 IRIS AVE
Mailing Address - Street 2:SUITE #103
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301
Mailing Address - Country:US
Mailing Address - Phone:303-447-2872
Mailing Address - Fax:303-447-2896
Practice Address - Street 1:3393 IRIS AVE
Practice Address - Street 2:SUITE #103
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301
Practice Address - Country:US
Practice Address - Phone:303-447-2872
Practice Address - Fax:303-447-2896
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6979122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist