Provider Demographics
NPI:1326931742
Name:JACKSON, BENJAMIN JOSEPH (DMD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOSEPH
Last Name:JACKSON
Suffix:
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 1:5101 LAKEVIEW PKWY UNIT 409
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3311
Mailing Address - Country:US
Mailing Address - Phone:501-617-1107
Mailing Address - Fax:
Practice Address - Street 1:7017 JOHN DEERE PKWY STE 2B
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-8037
Practice Address - Country:US
Practice Address - Phone:309-792-0513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-03
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.036026122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist