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General NPI Number Information
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NPI Number | 1649496910
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Entity Type | Individual
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Provider Name | CAROL D JACKSON D.D.S
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Gender | Female
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Dates
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Enumeration Date | 04/17/2007
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Last Update Date | 09/19/2012
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Provider Practice Location Address
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Address Line | 614 N GILBERT ST
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City | DANVILLE
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State | IL
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Zip | 61832-3940
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Country | US
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Telephone | 217-442-8790
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Fax | 217-442-8780
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Provider Business Mailing Address
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Address Line | 208 CRAIN HIGHWAY, SOUTHWEST
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City | GLEN BURNIE
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State | MD
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Zip | 21061
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Country | US
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Telephone | 310-498-0002
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Fax |
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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 | 14764
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License Number State | MD
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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 | 019023180
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License Number State | IL
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