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General NPI Number Information
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NPI Number | 1336243476
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Entity Type | Organization
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Legal Business Name | LLOYD BRENT JACKSON DMD PALLC
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Dates
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Enumeration Date | 09/11/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2700 FARMINGTON AVE SUITE C-1
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City | FARMINTON
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State | NM
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Zip | 87401-4550
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Country | US
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Telephone | 505-327-0044
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Fax | 505-325-0817
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Provider Business Mailing Address
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Address Line | 2700 FARMINGTON AVE SUITE C-1
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City | FARMINTON
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State | NM
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Zip | 87401-4550
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Country | US
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Telephone | 505-327-0044
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Fax | 505-325-0817
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | DR. LLOYD BRENT JACKSON
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Credential | DMD
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Telephone | 505-327-0044
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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