MEDICARE: DR. JEFFERY DALE HARTSOG DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2079-84	MS

General Provider Information

NPI Number	:	1518969633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFERY DALE HARTSOG DMD

Provider Business Mailing Address
First Line	:	1437 OLD SQUARE RD
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39211-5535
Country	:	US
Telephone Number	:	601-362-1685
Fax Number	:	601-982-9304

Provider Business Practice Location Address
First Line	:	1437 OLD SQUARE RD
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39211-5535
Country	:	US
Telephone Number	:	601-362-1685
Fax Number	:	601-982-9304

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	07/08/2007

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