Healthcare Provider Details

I. General information

NPI: 1972563690
Provider Name (Legal Business Name): CHARLES B JACKSON, JR. DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 UNION SQ
SANDY UT
84070-3404
US

IV. Provider business mailing address

669 UNION SQ
SANDY UT
84070-3404
US

V. Phone/Fax

Practice location:
  • Phone: 801-571-1231
  • Fax: 801-571-9738
Mailing address:
  • Phone: 801-571-1231
  • Fax: 801-571-9738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number142729-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: