Wayne Paul Jackman, DDS
Individual provider Active NPI General Practice Dentistry · Ravena, OH
NPI 1003071697 · NPPES record last updated Jul 23, 2008
Key facts
- NPI
- 1003071697
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Dentistry 1223G0001X
- License
- 019126 (OH)
- Practice address
- 444 S Meridian St
Ravena, OH 44233 - Phone
- (330) 297-6216
- NPI assigned
- Jul 23, 2008
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in OH
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160321000187 | OH | Order and Referring Only - Dentist |
8628375516 |
National Provider Directory
- Medicare enrollment (NPD)
- No
- HHS exclusion list flag
- The National Provider Directory flags this NPI as appearing on an HHS exclusion list.
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019126 | OH | MD | General Practice Dentistry |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 019126 | OH | Yes |
Addresses
Primary practice location
444 S Meridian St
Ravena, OH 44233
Mailing address
444 S Meridian St
Ravenna, OH 44266
Phone (330) 297-6216
Other providers in Ravena, OH
All providers in Ravena, OH · General Practice Dentistry in Ohio
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 23, 2008. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.