=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003862913
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICHARD L. JACKSON, D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3650 ERIE AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45208-1928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-321-3037
-----------------------------------------------------
Fax | 513-321-2071
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3650 ERIE AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45208-1928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-321-3037
-----------------------------------------------------
Fax | 513-321-2071
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / PRESIDENT
-----------------------------------------------------
Name | DR. RICHARD L. JACKSON
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 513-321-3037
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 17359
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------