MEDICARE: DR. DOLPHUS CARL JACKSON D.D.S., P.C.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DS08035	TN
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DS0000008035	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0015802	OTHER	TN	ASSURANT EMPLOYEE BNFTS
2	4105175	OTHER	TN	TENNCARE SELECT
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	9176594	OTHER	TN	DORAL USA
5	281433	OTHER	TN	CIGNA DMO DENTAL PLAN
6	4105175	OTHER	TN	BCBS OF TENNESSEE

General Provider Information

NPI Number	:	1467511642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOLPHUS CARL JACKSON D.D.S., P.C.

Provider Business Mailing Address
First Line	:	4012 OHALLORN DR STE A
Second Line	:
City	:	SPRING HILL
State	:	TN
Zip	:	37174-2214
Country	:	US
Telephone Number	:	615-302-8471
Fax Number	:	615-302-8081

Provider Business Practice Location Address
First Line	:	4012 OHALLORN DR STE A
Second Line	:
City	:	SPRING HILL
State	:	TN
Zip	:	37174-2214
Country	:	US
Telephone Number	:	615-302-8471
Fax Number	:	615-302-8081

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

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	03/12/2025

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Directions to “ DR. DOLPHUS CARL JACKSON D.D.S., P.C.” Practice Location

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