Provider Demographics
NPI:1396195152
Name:ROSS, JESSICA MARIE (DMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
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 1:301 SW BELAIR DR
Mailing Address - Street 2:PO BOX 899
Mailing Address - City:CLATSKANIE
Mailing Address - State:OR
Mailing Address - Zip Code:97016-7414
Mailing Address - Country:US
Mailing Address - Phone:503-728-2137
Mailing Address - Fax:503-728-3023
Practice Address - Street 1:301 SW BELAIR DR
Practice Address - Street 2:
Practice Address - City:CLATSKANIE
Practice Address - State:OR
Practice Address - Zip Code:97016-7414
Practice Address - Country:US
Practice Address - Phone:503-728-2137
Practice Address - Fax:503-728-3023
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10442122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist