Provider Demographics
NPI:1669702304
Name:JACKSON, GEOFFREY ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:ALAN
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 1:19048 BRUCE B DOWNS BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2434
Mailing Address - Country:US
Mailing Address - Phone:813-972-1201
Mailing Address - Fax:
Practice Address - Street 1:19048 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2434
Practice Address - Country:US
Practice Address - Phone:813-972-1201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 18870122300000X
MD14511122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist