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General NPI Number Information
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NPI Number | 1699858001
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Entity Type | Individual
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Provider Name | JACKSON D FORDHAM DMD
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Gender | Male
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 06/20/2016
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Provider Practice Location Address
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Address Line | 204 FAIRVIEW PARK DR
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City | DUBLIN
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State | GA
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Zip | 31021-2547
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Country | US
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Telephone | 478-272-4051
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Fax | 478-272-3310
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Provider Business Mailing Address
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Address Line | 204 FAIRVIEW PARK DR
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City | DUBLIN
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State | GA
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Zip | 31021-2547
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Country | US
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Telephone | 478-272-4051
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Fax | 478-272-3310
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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 | 9503
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License Number State | GA
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