Healthcare Provider Details

I. General information

NPI: 1427143643
Provider Name (Legal Business Name): JACKSON PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 N MADISON AVE
GREENWOOD IN
46142-3526
US

IV. Provider business mailing address

45 N MADISON AVE
GREENWOOD IN
46142-3526
US

V. Phone/Fax

Practice location:
  • Phone: 317-887-3180
  • Fax: 317-882-2718
Mailing address:
  • Phone: 317-887-3180
  • Fax: 317-882-2718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12009767
License Number StateIN

VIII. Authorized Official

Name: DR. KRISTIN M JACKSON
Title or Position: OWNER
Credential: DDS, MSD
Phone: 317-887-3180