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General NPI Number Information
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NPI Number | 1710546437
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Entity Type | Organization
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Legal Business Name | KYLE R. JACKSON, DDS, LLC
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Dates
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Enumeration Date | 06/06/2019
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Last Update Date | 06/06/2019
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Provider Practice Location Address
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Address Line | 4090 INDIAN RIPPLE RD UNIT 102
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City | BEAVERCREEK
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State | OH
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Zip | 45440-3253
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Country | US
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Telephone | 937-586-7729
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Fax | 937-490-9904
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Provider Business Mailing Address
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Address Line | 273 REGENCY RIDGE DR
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City | CENTERVILLE
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State | OH
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Zip | 45459-4221
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Country | US
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Telephone | 937-586-7729
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Fax | 937-660-4450
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Authorized Official
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Title or Position | OWNER
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Name | KYLE R. JACKSON
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Credential | DDS
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Telephone | 937-586-7729
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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