MEDICARE: JACKSON LAWLER ANDERSON 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	104589	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	010274	OTHER	CO	NATIONAL PAYOR ID

General Provider Information

NPI Number	:	1275742488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKSON LAWLER ANDERSON D.D.S.

Provider Business Mailing Address
First Line	:	6459 OMAHA BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-2618
Country	:	US
Telephone Number	:	719-597-9057
Fax Number	:	719-597-2189

Provider Business Practice Location Address
First Line	:	6459 OMAHA BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-2618
Country	:	US
Telephone Number	:	719-597-9057
Fax Number	:	719-597-2189

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

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/08/2007

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