Provider Demographics
NPI:1134371966
Name:JACKSON, NATHANIAL DAMON (DDS)
Entity type:Individual
Prefix:DR
First Name:NATHANIAL
Middle Name:DAMON
Last Name:JACKSON
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 W CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-2819
Mailing Address - Country:US
Mailing Address - Phone:520-670-3909
Mailing Address - Fax:520-309-2560
Practice Address - Street 1:839 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2819
Practice Address - Country:US
Practice Address - Phone:520-670-3909
Practice Address - Fax:520-309-2560
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054051122300000X
DCDEN1000767122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist