Provider Demographics
NPI:1881975191
Name:BRANDI R. JACKSON DDS, MS, PLLC
Entity type:Organization
Organization Name:BRANDI R. JACKSON DDS, MS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:R
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:704-895-6445
Mailing Address - Street 1:11223 DAVINCI DR
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-7799
Mailing Address - Country:US
Mailing Address - Phone:704-895-6445
Mailing Address - Fax:704-895-6496
Practice Address - Street 1:11223 DAVINCI DR
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-7799
Practice Address - Country:US
Practice Address - Phone:704-895-6445
Practice Address - Fax:704-895-6496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8224122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty