Healthcare Provider Details

I. General information

NPI: 1518969633
Provider Name (Legal Business Name): JEFFERY DALE HARTSOG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1437 OLD SQUARE RD
JACKSON MS
39211-5535
US

IV. Provider business mailing address

1437 OLD SQUARE RD
JACKSON MS
39211-5535
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-1685
  • Fax: 601-982-9304
Mailing address:
  • Phone: 601-362-1685
  • Fax: 601-982-9304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2079-84
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: