Basic Information
| Provider Information | |||||||||
| NPI: | 1629183777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | TANISHA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 422 ORANGE ST | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923743206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097927500 | ||||||||
| FaxNumber: | 9097927503 | ||||||||
| Practice Location | |||||||||
| Address1: | 2860 MICHELLE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926061009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145083600 | ||||||||
| FaxNumber: | 7143682092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 47103 | CA | Y | Dental Providers | Dentist | General Practice |
No ID Information.