Provider Demographics
NPI:1083398309
Name:MCGRATH, JACQUELINE ROSE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ROSE
Last Name:MCGRATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15503 OAK LN STE 300-B
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2697
Mailing Address - Country:US
Mailing Address - Phone:228-832-3231
Mailing Address - Fax:228-832-0186
Practice Address - Street 1:15503 OAK LN STE 300-B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2697
Practice Address - Country:US
Practice Address - Phone:228-832-3231
Practice Address - Fax:228-832-0186
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS43871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice