Provider Demographics
NPI:1720039878
Name:JACKSON, BRUCE ARDEN II (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ARDEN
Last Name:JACKSON
Suffix:II
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4829 E BELTLINE AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9747
Mailing Address - Country:US
Mailing Address - Phone:616-363-8707
Mailing Address - Fax:616-363-0390
Practice Address - Street 1:4829 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9747
Practice Address - Country:US
Practice Address - Phone:616-363-8707
Practice Address - Fax:616-363-0390
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-13
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI131621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4066190Medicaid