Healthcare Provider Details

I. General information

NPI: 1316153588
Provider Name (Legal Business Name): ROSS DENTAL CLINIC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 WOODLAND ST
MORTON MS
39117-3711
US

IV. Provider business mailing address

233 WOODLAND ST P.O. BOX 19
MORTON MS
39117-3711
US

V. Phone/Fax

Practice location:
  • Phone: 601-732-6200
  • Fax: 601-732-6624
Mailing address:
  • Phone: 601-732-6200
  • Fax: 601-732-6624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2747-93
License Number StateMS

VIII. Authorized Official

Name: DR. JAMIE EICHELBERGER ROSS
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 601-732-6200