Healthcare Provider Details

I. General information

NPI: 1801970769
Provider Name (Legal Business Name): GREGORY WAYNE JACKSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6435 S PULASKI RD
CHICAGO IL
60629-5148
US

IV. Provider business mailing address

6435 S PULASKI RD
CHICAGO IL
60629-5148
US

V. Phone/Fax

Practice location:
  • Phone: 773-767-0849
  • Fax: 773-767-0861
Mailing address:
  • Phone: 773-767-0849
  • Fax: 773-767-0861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: