Basic Information
| Provider Information | |||||||||
| NPI: | 1528247061 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MARYAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | VIII | ||||||||
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| Mailing Information | |||||||||
| Address1: | 677 S TWIN OAKS VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920787309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004174444 | ||||||||
| FaxNumber: | 7145713560 | ||||||||
| Practice Location | |||||||||
| Address1: | 2701 W 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927033443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149732022 | ||||||||
| FaxNumber: | 7148356954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 03/25/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 56397 | CA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | D56397 | 05 | CA | MEDICAID |