MEDICARE: DR. MICHAEL ROY JACKSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	11498	TX

General Provider Information

NPI Number	:	1083735369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL ROY JACKSON DDS

Provider Business Mailing Address
First Line	:	6924 SOUTH FWY
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76134-3800
Country	:	US
Telephone Number	:	817-293-7431
Fax Number	:	817-293-3848

Provider Business Practice Location Address
First Line	:	6924 SOUTH FWY
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76134-3800
Country	:	US
Telephone Number	:	817-293-7431
Fax Number	:	817-293-3848

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	07/08/2007

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6924 SOUTH FWY
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