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General NPI Number Information
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NPI Number | 1265624332
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Entity Type | Individual
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Provider Name | MARVIN BLANE JACKSON DDS
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Gender | Male
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Dates
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Enumeration Date | 08/13/2007
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Last Update Date | 10/06/2021
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Provider Practice Location Address
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Address Line | 4550 E BELL RD. ST. 102
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City | PHOENIX
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State | AZ
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Zip | 85032-9306
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Country | US
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Telephone | 602-485-1588
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Fax | 602-707-9740
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Provider Business Mailing Address
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Address Line | 230 N FAIRGROUNDS RD
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City | PRICE
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State | UT
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Zip | 84501-4205
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Country | US
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Telephone | 435-637-2100
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Fax | 435-637-5007
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 6605138-9921
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D010196
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License Number State | AZ
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