Provider Demographics
NPI:1568538965
Name:FCD OF JACKSON, PLLC
Entity type:Organization
Organization Name:FCD OF JACKSON, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINISH
Authorized Official - Middle Name:Y
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:731-424-6452
Mailing Address - Street 1:1523 S. HIGHLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-7520
Mailing Address - Country:US
Mailing Address - Phone:731-424-6452
Mailing Address - Fax:731-424-9719
Practice Address - Street 1:1523 S. HIGHLAND AVENUE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-7520
Practice Address - Country:US
Practice Address - Phone:731-424-6452
Practice Address - Fax:731-424-9719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1526237Medicaid