Provider Demographics
NPI:1922028356
Name:JACKSON, GLENN D (DMD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:D
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 1:9 NASON ST
Mailing Address - Street 2:
Mailing Address - City:MAYNARD
Mailing Address - State:MA
Mailing Address - Zip Code:01754
Mailing Address - Country:US
Mailing Address - Phone:978-847-9407
Mailing Address - Fax:978-897-3764
Practice Address - Street 1:9 NASON ST
Practice Address - Street 2:
Practice Address - City:MAYNARD
Practice Address - State:MA
Practice Address - Zip Code:01754
Practice Address - Country:US
Practice Address - Phone:978-847-9407
Practice Address - Fax:978-897-3764
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA146291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice