Provider Demographics
NPI:1306988571
Name:JACKSON, ROLLIN B III (DMD)
Entity type:Individual
Prefix:
First Name:ROLLIN
Middle Name:B
Last Name:JACKSON
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 134
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:GA
Mailing Address - Zip Code:31320-0134
Mailing Address - Country:US
Mailing Address - Phone:912-880-2288
Mailing Address - Fax:912-880-2110
Practice Address - Street 1:1718 N COASTAL HWY
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:GA
Practice Address - Zip Code:31320-3415
Practice Address - Country:US
Practice Address - Phone:912-880-2288
Practice Address - Fax:912-880-2110
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0130911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice