Healthcare Provider Details

I. General information

NPI: 1598788796
Provider Name (Legal Business Name): MARK K JACKSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 OLD SAUK ROAD
MADISON WI
53717
US

IV. Provider business mailing address

3556 TIMBER LANE
CROSS PLAINS WI
53528
US

V. Phone/Fax

Practice location:
  • Phone: 608-833-2060
  • Fax: 608-833-1737
Mailing address:
  • Phone: 608-798-3733
  • Fax: 608-833-1737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3459
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: