Healthcare Provider Details

I. General information

NPI: 1285857201
Provider Name (Legal Business Name): JOHN BENNETT ROSS V D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N 4TH ST
LONGVIEW TX
75601-5442
US

IV. Provider business mailing address

3452 SAM PAGE RD
LONGVIEW TX
75605-7555
US

V. Phone/Fax

Practice location:
  • Phone: 903-757-8890
  • Fax:
Mailing address:
  • Phone: 903-663-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12232
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: