Provider Demographics
NPI:1336243476
Name:LLOYD BRENT JACKSON DMD PALLC
Entity Type:Organization
Organization Name:LLOYD BRENT JACKSON DMD PALLC
Other - Org Name:FARMINGTON DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-327-0044
Mailing Address - Street 1:2700 FARMINGTON AVE
Mailing Address - Street 2:SUITE C-1
Mailing Address - City:FARMINTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4550
Mailing Address - Country:US
Mailing Address - Phone:505-327-0044
Mailing Address - Fax:505-325-0817
Practice Address - Street 1:2700 FARMINGTON AVE
Practice Address - Street 2:SUITE C-1
Practice Address - City:FARMINTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4550
Practice Address - Country:US
Practice Address - Phone:505-327-0044
Practice Address - Fax:505-325-0817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty