Healthcare Provider Details

I. General information

NPI: 1205911120
Provider Name (Legal Business Name): GREGORY W. JACKSON DDS, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 08/22/2020
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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. GREGORY WAYNE JACKSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 773-767-0849