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General NPI Number Information
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NPI Number | 1518969633
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Entity Type | Individual
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Provider Name | JEFFERY DALE HARTSOG DMD
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Gender | Male
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Dates
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Enumeration Date | 06/01/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1437 OLD SQUARE RD
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City | JACKSON
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State | MS
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Zip | 39211-5535
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Country | US
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Telephone | 601-362-1685
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Fax | 601-982-9304
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Provider Business Mailing Address
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Address Line | 1437 OLD SQUARE RD
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City | JACKSON
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State | MS
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Zip | 39211-5535
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Country | US
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Telephone | 601-362-1685
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Fax | 601-982-9304
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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 | 2079-84
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License Number State | MS
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