1467511642 NPI number — DR. DOLPHUS CARL JACKSON D.D.S., P.C.

Table of content: (NPI 1780073106)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467511642 NPI number — DR. DOLPHUS CARL JACKSON D.D.S., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
DOLPHUS
Provider Middle Name:
CARL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S., P.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1467511642
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4012 OHALLORN DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING HILL
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37174-2214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-302-8471
Provider Business Mailing Address Fax Number:
615-302-8081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4012 OHALLORN DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRING HILL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37174-2214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-302-8471
Provider Business Practice Location Address Fax Number:
615-302-8081
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  DS08035 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , with the licence number: DS0000008035 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0015802 . This is a "ASSURANT EMPLOYEE BNFTS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4105175 . This is a "TENNCARE SELECT" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3731118 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9176594 . This is a "DORAL USA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 281433 . This is a "CIGNA DMO DENTAL PLAN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4105175 . This is a "BCBS OF TENNESSEE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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