MEDICARE: FCD OF JACKSON, PLLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568538965
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FCD OF JACKSON, PLLC

Provider Business Mailing Address
First Line	:	1523 S. HIGHLAND AVENUE
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38301-7520
Country	:	US
Telephone Number	:	731-424-6452
Fax Number	:	731-424-9719

Provider Business Practice Location Address
First Line	:	1523 S. HIGHLAND AVENUE
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38301-7520
Country	:	US
Telephone Number	:	731-424-6452
Fax Number	:	731-424-9719

Authorized Official
Title or Position	:	DOCTOR/OWNER
Name	:	MINISH Y. PATEL
Credential	:	DR.
Telephone Number	:	731-424-6452

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	01/10/2025

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