MEDICARE: DR. MARIO MICHAEL JACKSON D.D.S.

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	4594T	NV

General Provider Information

NPI Number	:	1144302811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIO MICHAEL JACKSON D.D.S.

Provider Business Mailing Address
First Line	:	1013 HARP WAY
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-7889
Country	:	US
Telephone Number	:	702-505-3914
Fax Number	:

Provider Business Practice Location Address
First Line	:	1013 HARP WAY
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-7889
Country	:	US
Telephone Number	:	702-505-3914
Fax Number	:

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

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	07/08/2007

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