Provider Demographics
NPI:1649496910
Name:JACKSON, CAROL D (DDS)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 CRAIN HIGHWAY, SOUTHWEST
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061
Mailing Address - Country:US
Mailing Address - Phone:310-498-0002
Mailing Address - Fax:
Practice Address - Street 1:614 N GILBERT ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3940
Practice Address - Country:US
Practice Address - Phone:217-442-8790
Practice Address - Fax:217-442-8780
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14764122300000X
IL019023180122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist