Provider Demographics
NPI:1992482392
Name:SIDES, JACKSON (DDS)
Entity type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:
Last Name:SIDES
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 1:127 NORMANDY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-4536
Mailing Address - Country:US
Mailing Address - Phone:252-670-5994
Mailing Address - Fax:
Practice Address - Street 1:8210 FLOYD CURL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3923
Practice Address - Country:US
Practice Address - Phone:210-450-3715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13274122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist