Healthcare Provider Details

I. General information

NPI: 1205931599
Provider Name (Legal Business Name): RODNEY ALLEN JACKSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2517 SIR BARTON WAY STE 200
LEXINGTON KY
40509-2275
US

IV. Provider business mailing address

2517 SIR BARTON WAY STE 200
LEXINGTON KY
40509-2275
US

V. Phone/Fax

Practice location:
  • Phone: 859-543-2456
  • Fax: 859-543-2373
Mailing address:
  • Phone: 859-543-2456
  • Fax: 859-543-2373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7750
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: