1336243476 NPI number — LLOYD BRENT JACKSON DMD PALLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336243476 NPI number — LLOYD BRENT JACKSON DMD PALLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LLOYD BRENT JACKSON DMD PALLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FARMINGTON DENTAL CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336243476
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 FARMINGTON AVE
Provider Second Line Business Mailing Address:
SUITE C-1
Provider Business Mailing Address City Name:
FARMINTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87401-4550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-327-0044
Provider Business Mailing Address Fax Number:
505-325-0817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 FARMINGTON AVE
Provider Second Line Business Practice Location Address:
SUITE C-1
Provider Business Practice Location Address City Name:
FARMINTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87401-4550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-327-0044
Provider Business Practice Location Address Fax Number:
505-325-0817
Provider Enumeration Date:
09/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
LLOYD
Authorized Official Middle Name:
BRENT
Authorized Official Title or Position:
OWNER DENTIST
Authorized Official Telephone Number:
505-327-0044

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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