MEDICARE: DR. CHARLES B JACKSON, JR. DDS, MSD

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	142729-9921	UT

General Provider Information

NPI Number	:	1972563690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES B JACKSON, JR. DDS, MSD

Provider Business Mailing Address
First Line	:	669 UNION SQ
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84070-3404
Country	:	US
Telephone Number	:	801-571-1231
Fax Number	:	801-571-9738

Provider Business Practice Location Address
First Line	:	669 UNION SQ
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84070-3404
Country	:	US
Telephone Number	:	801-571-1231
Fax Number	:	801-571-9738

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

Provider Enumeration Date	:	03/25/2006
Last Update Date	:	07/08/2007

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