Provider Demographics
NPI:1902932809
Name:JACKSON-GEORGE, TOMICKA
Entity Type:Individual
Prefix:
First Name:TOMICKA
Middle Name:
Last Name:JACKSON-GEORGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 S POTOMAC ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-2250
Mailing Address - Country:US
Mailing Address - Phone:301-870-4553
Mailing Address - Fax:
Practice Address - Street 1:22329 GREENVIEW PKWY
Practice Address - Street 2:
Practice Address - City:GREAT MILLS
Practice Address - State:MD
Practice Address - Zip Code:20634-3491
Practice Address - Country:US
Practice Address - Phone:301-870-4553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD132871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice