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NPI Code Detail

MEDICARE: CENTERILLE PEDIATRIC DENTISTRY, KYLE R JACKSON, DDS, INC

MEDICARE: CENTERILLE PEDIATRIC DENTISTRY, KYLE R JACKSON, DDS, INC
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
11223P0221XPediatric Dentistry30018976OH

General Provider Information

NPI Number : 1386073112
Entity Type Code : Organization
Provider Name (Legal Business Name) : CENTERILLE PEDIATRIC DENTISTRY, KYLE R JACKSON, DDS, INC
Provider Business Mailing Address
First Line : 273 REGENCY RIDGE DR
Second Line :
City : CENTERVILLE
State : OH
Zip : 45459-4221
Country : US
Telephone Number : 937-586-7729
Fax Number : 937-660-4450
Provider Business Practice Location Address
First Line : 273 REGENCY RIDGE DR
Second Line :
City : CENTERVILLE
State : OH
Zip : 45459-4221
Country : US
Telephone Number : 937-586-7729
Fax Number : 937-660-4450
Authorized Official
Title or Position : DENTIST/OWNER
Name : DR. KYLE R. JACKSON
Credential : DDS
Telephone Number : 937-586-7729
Provider Enumeration Date : 11/02/2013
Last Update Date : 08/11/2016

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