Provider Demographics
NPI:1487785911
Name:JACKSON, LLOYD BRENT (DMD)
Entity type:Individual
Prefix:
First Name:LLOYD
Middle Name:BRENT
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 1:2700 FARMINGTON AVE
Mailing Address - Street 2:C -1
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4559
Mailing Address - Country:US
Mailing Address - Phone:505-327-0044
Mailing Address - Fax:505-325-0817
Practice Address - Street 1:2700 FARMINGTON AVE
Practice Address - Street 2:C -1
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4559
Practice Address - Country:US
Practice Address - Phone:505-327-0044
Practice Address - Fax:505-325-0817
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2248122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist