Provider Demographics
NPI:1124116066
Name:JACKSON, RICHARD FREDRICK (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:FREDRICK
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 SECRET RAVINE PKWY
Mailing Address - Street 2:SUITE 160
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-6044
Mailing Address - Country:US
Mailing Address - Phone:916-787-1515
Mailing Address - Fax:916-787-1516
Practice Address - Street 1:1441 SECRET RAVINE PKWY
Practice Address - Street 2:SUITE 160
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-6044
Practice Address - Country:US
Practice Address - Phone:916-787-1515
Practice Address - Fax:916-787-1516
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA244651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT42816Medicare ID - Type UnspecifiedMEDICARE