Provider Demographics
NPI:1861753949
Name:JACKSON, BRANDON JOSHUA (DDS)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:JOSHUA
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305
Mailing Address - Country:US
Mailing Address - Phone:917-626-3507
Mailing Address - Fax:
Practice Address - Street 1:70 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1748
Practice Address - Country:US
Practice Address - Phone:718-226-8851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
390200000X
NY056966-11223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY390200000XMedicaid