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General NPI Number Information
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NPI Number | 1225259104
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Entity Type | Individual
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Provider Name | ALICIA ANNE ROSE D.M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/01/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 350 W WOODROW WILSON AVE JACKSON MEDICAL MALL, SUITE 3516
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City | JACKSON
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State | MS
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Zip | 39213-7681
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Country | US
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Telephone | 601-987-5566
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Fax | 601-987-5595
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Provider Business Mailing Address
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Address Line | 5518 PINE LANE DR
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City | JACKSON
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State | MS
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Zip | 39211-4018
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Country | US
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Telephone | 601-899-9200
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Fax | 601-899-9200
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3196-01
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License Number State | MS
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