Healthcare Provider Details

I. General information

NPI: 1639783137
Provider Name (Legal Business Name): BRUCE A. JACKSON II, DDS, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4829 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-9747
US

IV. Provider business mailing address

4829 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-9747
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-8707
  • Fax:
Mailing address:
  • Phone: 616-363-8707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. BRUCE JACKSON II
Title or Position: OWNER
Credential: DDS
Phone: 616-363-8707