Healthcare Provider Details

I. General information

NPI: 1962511659
Provider Name (Legal Business Name): CYNTHIA L JACKSON DDS MS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 ALPINE BLVD STE 212
ALPINE CA
91901-1105
US

IV. Provider business mailing address

1620 ALPINE BLVD STE 212
ALPINE CA
91901-1105
US

V. Phone/Fax

Practice location:
  • Phone: 619-445-8883
  • Fax: 619-445-8890
Mailing address:
  • Phone: 619-445-8883
  • Fax: 619-445-8890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number37034
License Number StateCA

VIII. Authorized Official

Name: MS. CYNTHIA LEE JACKSON
Title or Position: OWNER
Credential: DDS MS
Phone: 619-445-8883