Healthcare Provider Details

I. General information

NPI: 1578789616
Provider Name (Legal Business Name): JAMIE EICHELBERGER ROSS D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 WOODLAND ST
MORTON MS
39117-0019
US

IV. Provider business mailing address

233 WOODLAND ST POST OFFICE BOX 19
MORTON MS
39117-0019
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:
Title or Position:
Credential:
Phone: