Healthcare Provider Details

I. General information

NPI: 1992482392
Provider Name (Legal Business Name): JACKSON SIDES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 FALLS OF NEUSE RD # 100
RALEIGH NC
27615-5318
US

IV. Provider business mailing address

7501 FALLS OF NEUSE RD # 100
RALEIGH NC
27615-5318
US

V. Phone/Fax

Practice location:
  • Phone: 919-846-2480
  • Fax:
Mailing address:
  • Phone: 919-846-2480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13274
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: