Provider Demographics
NPI:1801970769
Name:JACKSON, GREGORY WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:WAYNE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6435 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-5148
Mailing Address - Country:US
Mailing Address - Phone:773-767-0849
Mailing Address - Fax:773-767-0861
Practice Address - Street 1:6435 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-5148
Practice Address - Country:US
Practice Address - Phone:773-767-0849
Practice Address - Fax:773-767-0861
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics