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General NPI Number Information
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NPI Number | 1447460357
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Entity Type | Organization
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Legal Business Name | JOHN P. JACKSON D.D.S., P.C.
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 10/01/2007
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Provider Practice Location Address
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Address Line | 109 S FRANKLIN ST
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City | FARMINGTON
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State | MO
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Zip | 63640-2516
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Country | US
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Telephone | 573-756-6415
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Fax | 573-756-6416
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Provider Business Mailing Address
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Address Line | 109 S FRANKLIN ST
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City | FARMINGTON
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State | MO
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Zip | 63640-2516
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Country | US
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Telephone | 573-756-6415
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Fax | 573-756-6416
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN P JACKSON
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Credential | D.D.S.
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Telephone | 573-756-6415
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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 | 11953
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License Number State | MO
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