Provider Demographics
NPI:1396431060
Name:JACKSON DENTAL ALLIANCE, PLLC
Entity type:Organization
Organization Name:JACKSON DENTAL ALLIANCE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:COREY
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-406-6780
Mailing Address - Street 1:2740 S MOUNT JULIET RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-6202
Mailing Address - Country:US
Mailing Address - Phone:615-406-6780
Mailing Address - Fax:
Practice Address - Street 1:40 W CALDWELL ST STE 202
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3179
Practice Address - Country:US
Practice Address - Phone:615-758-7511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental