Individual
CHARLES RUSSELL JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1 MED CENTER DIRVE, MORGANTOWN, WV 26506
(304) 293-2240
Mailing address
1 MED CENTER DIRVE, MORGANTOWN, WV 26506
(304) 293-2240
Taxonomy
Speciality
Code
Description
License number
State
1223E0200X
Endodontics
Primary
2122
WV
Other
Enumeration date
10/20/2006
Last updated
07/08/2007
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