Provider Demographics
NPI:1730409798
Name:JACKSON, MEGAN GRACE (DMD)
Entity type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:GRACE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3161 HEMINGWAY LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1859
Mailing Address - Country:US
Mailing Address - Phone:859-559-5466
Mailing Address - Fax:
Practice Address - Street 1:105 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40507-2109
Practice Address - Country:US
Practice Address - Phone:859-559-5466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-01
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY89001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty