Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | DI16549 | NJ |
NPI | 1851541601 |
---|---|
Provider Name | Dr. John Jackson |
First Address | Saddle River, NJ 07458-3057 |
Second Address | Saddle River, NJ 07458-3057 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/09/2008 |
Last Update Date | 29/09/2008 |