Healthcare Provider Details

I. General information

NPI: 1669642336
Provider Name (Legal Business Name): JONATHAN HAROLD ROSS D.D.S.,M.H.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2008
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5825 LANDERBROOK DR STE. 221
MAYFIELD HTS OH
44124-6532
US

IV. Provider business mailing address

5825 LANDERBROOK DR STE. 221
MAYFIELD HTS OH
44124-6532
US

V. Phone/Fax

Practice location:
  • Phone: 440-461-6008
  • Fax: 440-461-9282
Mailing address:
  • Phone: 440-461-6008
  • Fax: 440-461-9282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30023878
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4408
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number4408
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number30023878
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: