Healthcare Provider Details

I. General information

NPI: 1376459966
Provider Name (Legal Business Name): RAY LAWRENCE JACKSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RAYJ LAWRENCE JACKSON DDS

II. Dates (important events)

Enumeration Date: 08/22/2026
Last Update Date: 08/22/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 W GOVERNMENT WAY STE 1A
SEATTLE WA
98199-1461
US

IV. Provider business mailing address

3150 W GOVERNMENT WAY STE 1A
SEATTLE WA
98199-1461
US

V. Phone/Fax

Practice location:
  • Phone: 206-402-3904
  • Fax:
Mailing address:
  • Phone: 206-402-3904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDENT.DE.70137351
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: