Healthcare Provider Details

I. General information

NPI: 1922147214
Provider Name (Legal Business Name): RONALD DAVID JACKSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 E FEDERAL STREET
MIDDLEBURG VA
20118
US

IV. Provider business mailing address

PO BOX 1060
MIDDLEBURG VA
20118-1060
US

V. Phone/Fax

Practice location:
  • Phone: 540-687-8075
  • Fax: 540-364-9112
Mailing address:
  • Phone: 540-687-8075
  • Fax: 540-364-9112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4253
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: