MEDICARE: DR. LLOYD 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	122300000X	Dentist	12005914A	IN

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	:	1780710582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LLOYD JACKSON DDS

Provider Business Mailing Address
First Line	:	2100 E LAKE COOK RD
Second Line	:	SUITE 1100
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-1999
Country	:	US
Telephone Number	:	847-580-5954
Fax Number	:	877-821-6402

Provider Business Practice Location Address
First Line	:	2100 E LAKE COOK RD
Second Line	:	SUITE 1100
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-1999
Country	:	US
Telephone Number	:	847-580-5954
Fax Number	:

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

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	08/21/2012

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