Provider Demographics
NPI:1194256685
Name:ROSS, NARISSA C (DMD)
Entity type:Individual
Prefix:DR
First Name:NARISSA
Middle Name:C
Last Name:ROSS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 WALKING TRAIL WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-4818
Mailing Address - Country:US
Mailing Address - Phone:334-412-2014
Mailing Address - Fax:
Practice Address - Street 1:1821 BELTLINE RD SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601
Practice Address - Country:US
Practice Address - Phone:256-801-0039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-25
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0006569-C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1194256685Medicaid