MEDICARE: ROSS JACKSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	29058	TX

General Provider Information

NPI Number	:	1134552771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSS JACKSON DDS

Provider Business Mailing Address
First Line	:	5005 GALLERIA
Second Line	:	# 3216
City	:	DALLAS
State	:	TX
Zip	:	75244-5331
Country	:	US
Telephone Number	:	972-658-3048
Fax Number	:

Provider Business Practice Location Address
First Line	:	5005 GALLERIA
Second Line	:	# 3216
City	:	DALLAS
State	:	TX
Zip	:	75244-5331
Country	:	US
Telephone Number	:	972-658-3048
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2013
Last Update Date	:	08/19/2013

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