Provider Demographics
NPI:1710381256
Name:JACKSON, ALICIA RENEE (DDS)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 E JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-7307
Mailing Address - Country:US
Mailing Address - Phone:631-427-4327
Mailing Address - Fax:
Practice Address - Street 1:245 5TH AVE FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-8728
Practice Address - Country:US
Practice Address - Phone:917-747-6574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057371-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist