Provider Demographics
NPI:1528075355
Name:JACKSON, ROBERT E (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:E
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 1:1012 W HEBRON PKWY STE 108
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-1123
Mailing Address - Country:US
Mailing Address - Phone:972-492-1064
Mailing Address - Fax:972-492-2483
Practice Address - Street 1:1012 W HEBRON PKWY STE 108
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-1123
Practice Address - Country:US
Practice Address - Phone:972-492-1064
Practice Address - Fax:972-492-2483
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18030122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist