Provider Demographics
NPI:1306940994
Name:JACKSON, TERENCE STEWART (DMD MA)
Entity type:Individual
Prefix:DR
First Name:TERENCE
Middle Name:STEWART
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DMD MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 OAK ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905
Mailing Address - Country:US
Mailing Address - Phone:203-252-2252
Mailing Address - Fax:203-504-6270
Practice Address - Street 1:47 OAK ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905
Practice Address - Country:US
Practice Address - Phone:203-252-2252
Practice Address - Fax:203-504-6270
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0094111223P0300X
MA202711223P0300X
NY05188511223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics