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Organization

CLUBHOUSE PEDIATRIC DENTISTRY OF JACKSON

Active
Organization subpart
No

Provider details

NPI number
Authorized official
DR. COURTNEY MATTHEW JACKSON DDS (PEDIATRIC DENTIST)
(307) 733-5439
Entity
Organization

Contact information

Practice address
1130 US-89, JACKSON HOLE, WY 83001-8701
(307) 733-5439
Mailing address
3210 E 81ST S, IDAHO FALLS, ID 83406-8302
(307) 733-5439

Taxonomy

Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary

Other

Enumeration date
10/05/2018
Last updated
10/05/2018
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