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General NPI Number Information
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NPI Number | 1871930099
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Entity Type | Individual
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Provider Name | MELISSA D JACKSON DMD
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Gender | Female
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Dates
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Enumeration Date | 05/29/2013
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Last Update Date | 10/17/2024
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Provider Practice Location Address
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Address Line | EDGEWOOD DENTAL 7 MUNICIPAL WAY
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City | EDGEWOOD
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State | NM
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Zip | 87015
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Country | US
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Telephone | 505-281-3406
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 913353
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City | DENVER
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State | CO
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Zip | 80291-2678
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Country | US
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Telephone | 505-241-5182
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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 | DD3828
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License Number State | NM
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