MEDICARE: JACKSON DENTAL CARE, PLLC

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	192481	MS
2	122300000X	Dentist	235987	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	208026392	OTHER	MS	TAX ID#
2	1285640383	OTHER	MS	NPI
3	1669488763	OTHER	MS	NPI

General Provider Information

NPI Number	:	1386867414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON DENTAL CARE, PLLC

Provider Business Mailing Address
First Line	:	2655 LAKELAND DR
Second Line	:
City	:	FLOWOOD
State	:	MS
Zip	:	39232-9516
Country	:	US
Telephone Number	:	601-932-8212
Fax Number	:	601-939-8169

Provider Business Practice Location Address
First Line	:	2655 LAKELAND DR
Second Line	:
City	:	FLOWOOD
State	:	MS
Zip	:	39232-9516
Country	:	US
Telephone Number	:	601-932-8212
Fax Number	:	601-939-8169

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. SHIRLEY G WALKER
Credential	:
Telephone Number	:	601-932-8212

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	06/18/2008

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