Provider Demographics
NPI:1992346597
Name:JACKSON, DAVID KEITH II (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:KEITH
Last Name:JACKSON
Suffix:II
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 1:1120 LOCHWOOD PL
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-4044
Mailing Address - Country:US
Mailing Address - Phone:858-531-0829
Mailing Address - Fax:
Practice Address - Street 1:19871 MITSCHER WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92145-5103
Practice Address - Country:US
Practice Address - Phone:858-577-1825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1041641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice