Healthcare Provider Details

I. General information

NPI: 1922191915
Provider Name (Legal Business Name): DANA C. JACKSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6710 OXON HILL RD SUITE #350
OXON HILL MD
20745-1121
US

IV. Provider business mailing address

2203 PARKSIDE DR
MITCHELLVILLE MD
20721-4228
US

V. Phone/Fax

Practice location:
  • Phone: 301-248-3810
  • Fax: 301-449-6746
Mailing address:
  • Phone: 301-390-2575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN4466
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9883
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: