Provider Demographics
NPI:1457515330
Name:JACKSON, ROBERT ANTHONY (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ANTHONY
Last Name:JACKSON
Suffix:
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 1:2816 VEACH RD.
Mailing Address - Street 2:UNIT 305
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303
Mailing Address - Country:US
Mailing Address - Phone:270-683-5344
Mailing Address - Fax:270-683-3519
Practice Address - Street 1:2816 VEACH RD.
Practice Address - Street 2:UNIT 305
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303
Practice Address - Country:US
Practice Address - Phone:270-386-5344
Practice Address - Fax:270-683-3519
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY86091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice