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General NPI Number Information
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NPI Number | 1811429905
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Entity Type | Individual
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Provider Name | MARIA O. JACKSON D.D.S.
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Gender | Female
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Dates
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Enumeration Date | 03/29/2017
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 5330 E MOCKINGBIRD LN STE 120
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City | DALLAS
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State | TX
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Zip | 75206-0941
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Country | US
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Telephone | 214-821-5011
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Fax |
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Provider Business Mailing Address
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Address Line | 1113 SYCAMORE RIDGE DR
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City | LANSING
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State | KS
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Zip | 66043-6314
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Country | US
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Telephone |
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 61175
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 32785
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License Number State | TX
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