MEDICARE: DR. RICHARD K JACKSON DDS

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	DN12332	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629046339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD K JACKSON DDS

Provider Business Mailing Address
First Line	:	1975 SANSBURYS WAY STE 112
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-1928
Country	:	US
Telephone Number	:	561-737-6445
Fax Number	:	561-792-5977

Provider Business Practice Location Address
First Line	:	1975 SANSBURYS WAY STE 112
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-1928
Country	:	US
Telephone Number	:	561-737-6445
Fax Number	:	561-792-5977

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

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	02/13/2020

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