MEDICARE: DR. GEOFFREY ALAN 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	122300000X	Dentist	DN 18870	FL
2	122300000X	Dentist	14511	MD

General Provider Information

NPI Number	:	1669702304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEOFFREY ALAN JACKSON DDS

Provider Business Mailing Address
First Line	:	19048 BRUCE B DOWNS BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-2434
Country	:	US
Telephone Number	:	813-972-1201
Fax Number	:

Provider Business Practice Location Address
First Line	:	19048 BRUCE B DOWNS BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-2434
Country	:	US
Telephone Number	:	813-972-1201
Fax Number	:

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

Provider Enumeration Date	:	12/31/2009
Last Update Date	:	12/31/2009

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