Provider Demographics
NPI:1225259104
Name:ROSE, ALICIA ANNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:ANNE
Last Name:ROSE
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 1:5518 PINE LANE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4018
Mailing Address - Country:US
Mailing Address - Phone:601-899-9200
Mailing Address - Fax:601-899-9200
Practice Address - Street 1:350 W WOODROW WILSON AVE
Practice Address - Street 2:JACKSON MEDICAL MALL, SUITE 3516
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:601-987-5566
Practice Address - Fax:601-987-5595
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3196-011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice