Basic Information
Provider Information
NPI: 1114368917
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JACKSON
FirstName: SEAN
MiddleName:  
NamePrefix: MR.
NameSuffix:  
Credential: RDH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 111 W 7 MILE RD
Address2:  
City: DETROIT
State: MI
PostalCode: 482031968
CountryCode: US
TelephoneNumber: 3133692600
FaxNumber: 3133692477
Practice Location
Address1: 111 W 7 MILE RD
Address2:  
City: DETROIT
State: MI
PostalCode: 482031968
CountryCode: US
TelephoneNumber: 3133692600
FaxNumber: 3133692477
Other Information
ProviderEnumerationDate: 07/10/2013
LastUpdateDate: 07/10/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
124Q00000X2902014962MIY Dental ProvidersDental Hygienist 

No ID Information.


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