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General NPI Number Information
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NPI Number | 1932294741
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Entity Type | Organization
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Legal Business Name | SCOTT ROBERT JACKSON DDS PC
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 13660 N 94TH DR SUITE A1 PLAZA DEL RIO MEDICAL CENTER
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City | PEORIA
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State | AZ
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Zip | 85381-4836
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Country | US
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Telephone | 623-933-0550
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Fax | 623-933-2722
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Provider Business Mailing Address
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Address Line | 13660 N 94TH DR SUITE #A1
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City | PEORIA
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State | AZ
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Zip | 85381-4836
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Country | US
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Telephone | 623-933-0550
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Fax | 623-933-2722
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SCOTT ROBERT JACKSON
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Credential | DDS PC
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Telephone | 623-933-0550
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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 | 2532
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License Number State | AZ
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