Provider Demographics
NPI:1518969633
Name:HARTSOG, JEFFERY DALE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:DALE
Last Name:HARTSOG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1437 OLD SQUARE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5535
Mailing Address - Country:US
Mailing Address - Phone:601-362-1685
Mailing Address - Fax:601-982-9304
Practice Address - Street 1:1437 OLD SQUARE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5535
Practice Address - Country:US
Practice Address - Phone:601-362-1685
Practice Address - Fax:601-982-9304
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2079-841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice