Provider Demographics
NPI:1992904155
Name:JACKSON, STEPHANIE LYNN (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13521 STEELECROFT PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-7545
Mailing Address - Country:US
Mailing Address - Phone:704-714-5380
Mailing Address - Fax:704-714-5380
Practice Address - Street 1:13521 STEELECROFT PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-7545
Practice Address - Country:US
Practice Address - Phone:704-714-5380
Practice Address - Fax:704-714-5380
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC84121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911548Medicaid
NC7328546Medicare UPIN