=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164634440
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MABLETON DENTAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5841 MABLETON PKWY
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-944-8700
-----------------------------------------------------
Fax | 770-819-1190
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1159
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-944-8700
-----------------------------------------------------
Fax | 770-819-1190
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST, OWNER
-----------------------------------------------------
Name | DR. ROLLIN B. JACKSON JR.
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 770-944-8700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------