Provider Demographics
NPI:1922191915
Name:JACKSON, DANA C (DDS)
Entity type:Individual
Prefix:DR
First Name:DANA
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MITCHELLVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-4228
Mailing Address - Country:US
Mailing Address - Phone:301-390-2575
Mailing Address - Fax:
Practice Address - Street 1:6710 OXON HILL RD
Practice Address - Street 2:SUITE #350
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-1121
Practice Address - Country:US
Practice Address - Phone:301-248-3810
Practice Address - Fax:301-449-6746
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN44661223S0112X
MD98831223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCU42029Medicare UPIN
DC654307Medicare ID - Type Unspecified