MEDICARE: ANTHONY 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	4079	LA

General Provider Information

NPI Number	:	1730218132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY JACKSON DDS

Provider Business Mailing Address
First Line	:	1101 RURAL ST
Second Line	:
City	:	RIVER RIDGE
State	:	LA
Zip	:	70123-2745
Country	:	US
Telephone Number	:	504-737-9416
Fax Number	:

Provider Business Practice Location Address
First Line	:	9541 JEFFERSON HWY
Second Line	:
City	:	RIVER RIDGE
State	:	LA
Zip	:	70123-2507
Country	:	US
Telephone Number	:	504-738-1567
Fax Number	:

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

Provider Enumeration Date	:	03/04/2007
Last Update Date	:	07/08/2007

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