MEDICARE: BENITA S. 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	1223G0001X	General Practice Dentistry	DS7142	TN

General Provider Information

NPI Number	:	1275517781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENITA S. JACKSON D.D.S.

Provider Business Mailing Address
First Line	:	617 WOODLAND ST
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37206-4211
Country	:	US
Telephone Number	:	615-299-5666
Fax Number	:

Provider Business Practice Location Address
First Line	:	617 WOODLAND ST
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37206-4211
Country	:	US
Telephone Number	:	615-256-2321
Fax Number	:	615-256-2329

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

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	09/27/2011

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