Healthcare Provider Details

I. General information

NPI: 1972610947
Provider Name (Legal Business Name): TIMOTHY MICHAEL JACKSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 DRAYTON AVENUE
ELBA AL
36323
US

IV. Provider business mailing address

PO BOX 450
ELBA AL
36323
US

V. Phone/Fax

Practice location:
  • Phone: 334-897-3418
  • Fax: 334-897-3438
Mailing address:
  • Phone: 334-897-3418
  • Fax: 334-897-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4025
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: