Healthcare Provider Details

I. General information

NPI: 1790601946
Provider Name (Legal Business Name): ROSS JARED REDDOCK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MARINE CENTERED MEDICAL HOME WALLACE CREEK, BLDG. WC 2 BIRCH ST
CAMP LEJEUNE NC
28542
US

IV. Provider business mailing address

54 FOUNTAIN LN
JERICHO NY
11753-2317
US

V. Phone/Fax

Practice location:
  • Phone: 910-451-6122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14883
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: