MEDICARE: DR. HENRY LEE JACKSON JR. 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	10922	NC

General Provider Information

NPI Number	:	1699213959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HENRY LEE JACKSON JR. DDS

Provider Business Mailing Address
First Line	:	145 CROWNE CHASE DR APT 16
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27104-3582
Country	:	US
Telephone Number	:	631-671-1137
Fax Number	:

Provider Business Practice Location Address
First Line	:	334 E HANES MILL RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27105-9135
Country	:	US
Telephone Number	:	336-450-2077
Fax Number	:

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

Provider Enumeration Date	:	02/07/2017
Last Update Date	:	10/23/2018

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