MEDICARE: DR. BASIL JACKSON FRIEND II 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	0401007135	VA

General Provider Information

NPI Number	:	1316233851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BASIL JACKSON FRIEND II D.D.S

Provider Business Mailing Address
First Line	:	15806 JEFFERSON DAVIS HWY
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-5202
Country	:	US
Telephone Number	:	804-520-8994
Fax Number	:

Provider Business Practice Location Address
First Line	:	15806 JEFFERSON DAVIS HWY
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-5202
Country	:	US
Telephone Number	:	804-520-8994
Fax Number	:

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

Provider Enumeration Date	:	06/23/2011
Last Update Date	:	06/23/2011

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