Provider Demographics
NPI:1619538436
Name:JACKSON, RYNE (DMD, MSD)
Entity type:Individual
Prefix:
First Name:RYNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24125 N 160TH AVE
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85387-1629
Mailing Address - Country:US
Mailing Address - Phone:480-353-6476
Mailing Address - Fax:
Practice Address - Street 1:15294 W BROOKSIDE LN STE 100
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2446
Practice Address - Country:US
Practice Address - Phone:623-376-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7005122300000X
AZD0120241223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentistGroup - Single Specialty