Provider Demographics
NPI:1871586990
Name:JACKSON, RON DARRYL (DDS)
Entity type:Individual
Prefix:MR
First Name:RON
Middle Name:DARRYL
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 1:4211 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108
Mailing Address - Country:US
Mailing Address - Phone:314-367-5820
Mailing Address - Fax:314-367-7010
Practice Address - Street 1:5471 DR MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-4265
Practice Address - Country:US
Practice Address - Phone:314-367-5820
Practice Address - Fax:314-367-7010
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO012608122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO403231020Medicaid
MO403231038Medicaid
MO403231020Medicaid
MO232701200Medicare ID - Type Unspecified