Doctor Name: | KEVIN R JACKSON |
NPI Number: | 1265570683 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | DDS |
License Number: | DN012902 |
Business Practice Address: | 4150 Macland Rd Suite 205 Powder Springs, GA - 301271202 |
Business Phone Number: | 7702221344 |
Business Fax Number: | 7702221345 |
Mailing Address: | 5605 Maxon Marsh Dr, HIRAM |
State: | GA |
Postal Code: | 301412880 |
Phone Number: | |
Fax Number: | |
NPI Enumeration Date: | 02/01/2007 |
NPI Last Update Date: | 07/10/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 1223P0221X |
License Number: | DN012902 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | GA |
Taxonomy Type: | Dental Providers |
Taxonomy Classification: | Dentist |
Taxonomy Specialization: | Pediatric Dentistry |
Taxonomy Definition: | An age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs. |