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General NPI Number Information
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NPI Number | 1053972646
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Entity Type | Individual
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Provider Name | JATERRA DOMINIQUE ROSS DMD
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Gender | Female
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Dates
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Enumeration Date | 06/24/2019
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Last Update Date | 06/24/2019
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Provider Practice Location Address
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Address Line | 12300 DORSETT RD
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City | MARYLAND HEIGHTS
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State | MO
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Zip | 63043-3906
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Country | US
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Telephone | 314-254-4000
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Fax | 314-732-1826
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Provider Business Mailing Address
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Address Line | 7407 CEDAR DR
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City | GODFREY
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State | IL
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Zip | 62035-2710
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Country | US
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Telephone | 847-404-7029
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2019021855
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License Number State | MO
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