Provider Demographics
NPI:1578789616
Name:ROSS, JAMIE EICHELBERGER (DMD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:EICHELBERGER
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 1:233 WOODLAND ST
Mailing Address - Street 2:POST OFFICE BOX 19
Mailing Address - City:MORTON
Mailing Address - State:MS
Mailing Address - Zip Code:39117-0019
Mailing Address - Country:US
Mailing Address - Phone:601-732-6200
Mailing Address - Fax:601-732-6624
Practice Address - Street 1:233 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:MS
Practice Address - Zip Code:39117-0019
Practice Address - Country:US
Practice Address - Phone:601-732-6200
Practice Address - Fax:601-732-6624
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2747-931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660051Medicaid