=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467591735
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOSEPH L JACKSON DMD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 08/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2719 LIMESTONE PARKWAY
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-532-7400
-----------------------------------------------------
Fax | 770-532-1140
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2719 LIMESTONE PARKWAY
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-532-7400
-----------------------------------------------------
Fax | 770-532-1140
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | JOSEPH LOY JACKSON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 770-532-7400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------