Provider Demographics
NPI:1316153588
Name:ROSS DENTAL CLINIC P.C.
Entity type:Organization
Organization Name:ROSS DENTAL CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:EICHELBERGER
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-732-6200
Mailing Address - Street 1:233 WOODLAND ST
Mailing Address - Street 2:P.O. BOX 19
Mailing Address - City:MORTON
Mailing Address - State:MS
Mailing Address - Zip Code:39117-3711
Mailing Address - Country:US
Mailing Address - Phone:601-732-6200
Mailing Address - Fax:601-732-6624
Practice Address - Street 1:233 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:MS
Practice Address - Zip Code:39117-3711
Practice Address - Country:US
Practice Address - Phone:601-732-6200
Practice Address - Fax:601-732-6624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2747-931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660051Medicaid