Provider Demographics
NPI:1558106682
Name:JACKED DMD, PLLC
Entity type:Organization
Organization Name:JACKED DMD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:CHRISTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-985-9883
Mailing Address - Street 1:1534 SUMTER LN
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-8740
Mailing Address - Country:US
Mailing Address - Phone:860-985-9883
Mailing Address - Fax:
Practice Address - Street 1:2186 HARRIS AVE NE STE 3
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4044
Practice Address - Country:US
Practice Address - Phone:321-723-2620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-29
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental