Provider Demographics
NPI:1093409153
Name:ROSS, JASON (DDS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BORDEAUX DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5749
Mailing Address - Country:US
Mailing Address - Phone:901-277-0260
Mailing Address - Fax:
Practice Address - Street 1:105 BROADMOOR DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6651
Practice Address - Country:US
Practice Address - Phone:601-856-5227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4368-231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice