Provider Demographics
NPI:1730159849
Name:JACKSON, KYLE R (DDS)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:273 REGENCY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4221
Mailing Address - Country:US
Mailing Address - Phone:937-586-7729
Mailing Address - Fax:937-660-4450
Practice Address - Street 1:273 REGENCY RIDGE DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4221
Practice Address - Country:US
Practice Address - Phone:937-586-7729
Practice Address - Fax:937-660-4450
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-89761223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry