Provider Demographics
NPI:1194115865
Name:JACKSON FAMILY DENTAL GLADSTONE LLC
Entity type:Organization
Organization Name:JACKSON FAMILY DENTAL GLADSTONE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-429-5799
Mailing Address - Street 1:2109 NE 72ND ST
Mailing Address - Street 2:STE 104
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64118-2304
Mailing Address - Country:US
Mailing Address - Phone:816-453-3100
Mailing Address - Fax:816-453-3180
Practice Address - Street 1:2109 NE 72ND ST
Practice Address - Street 2:STE 104
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118-2304
Practice Address - Country:US
Practice Address - Phone:816-453-3100
Practice Address - Fax:816-453-3180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty