Individual
DR. BRANDON JOSHUA JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.D.S
Contact information
Practice address
70 VIRGINIA AVE, STATEN ISLAND, NY 10305-1748
(718) 226-8851
Mailing address
70 VIRGINIA AVE, STATEN ISLAND, NY 10305
(917) 626-3507
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
056966-1
NY
390200000X
Student in an Organized Health Care Education/Training Program
—
NY
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
390200000X
—
NY
Enumeration date
06/05/2012
Last updated
09/15/2015
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