MEDICARE: DR. LOIS ANN JACKSON 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	1223P0221X	Pediatric Dentistry	033223	NY

General Provider Information

NPI Number	:	1477762391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LOIS ANN JACKSON D.D.S.

Provider Business Mailing Address
First Line	:	505 LAGUARDIA PL
Second Line	:	L4
City	:	NEW YORK
State	:	NY
Zip	:	10012-2001
Country	:	US
Telephone Number	:	212-995-8888
Fax Number	:	212-995-0131

Provider Business Practice Location Address
First Line	:	505 LAGUARDIA PL
Second Line	:	L4
City	:	NEW YORK
State	:	NY
Zip	:	10012-2001
Country	:	US
Telephone Number	:	212-995-8888
Fax Number	:	212-995-0131

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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