Provider Demographics
NPI:1841848421
Name:KEITH JACKSON, TAYLER YVETTE (DDS)
Entity type:Individual
Prefix:
First Name:TAYLER
Middle Name:YVETTE
Last Name:KEITH 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 1:5140 JIMMY LEE SMITH PKWY
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-2745
Mailing Address - Country:US
Mailing Address - Phone:770-439-1038
Mailing Address - Fax:
Practice Address - Street 1:5140 JIMMY LEE SMITH PKWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2745
Practice Address - Country:US
Practice Address - Phone:770-439-1038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2021-09-24
Deactivation Date:2021-09-13
Deactivation Code:
Reactivation Date:2021-09-23
Provider Licenses
StateLicense IDTaxonomies
DCDEN10020331223G0001X
GADN122496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice