Provider Demographics
NPI:1811429905
Name:JACKSON, MARIA O (DDS)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:O
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 1:1113 SYCAMORE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:KS
Mailing Address - Zip Code:66043-6314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5330 E MOCKINGBIRD LN STE 120
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-0941
Practice Address - Country:US
Practice Address - Phone:214-821-5011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS611751223G0001X
TX327851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty