Provider Demographics
NPI:1770513046
Name:JACKSON, SCOTT A (DMD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
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 1:1910 SE 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-8312
Mailing Address - Country:US
Mailing Address - Phone:352-732-8544
Mailing Address - Fax:352-732-6855
Practice Address - Street 1:1910 SE 18TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-8312
Practice Address - Country:US
Practice Address - Phone:352-732-8544
Practice Address - Fax:352-732-6855
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 00140311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59175333OtherBC/BS OF ALABAMA
FL867365OtherUNITED CONCORDIA
FLJA1B0355OtherBC/BS OF MASS