Provider Demographics
NPI:1356554083
Name:ROSS, JODY LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:JODY
Middle Name:LEE
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 1:22 THE CRESCENT
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042
Mailing Address - Country:US
Mailing Address - Phone:973-509-8222
Mailing Address - Fax:973-509-8228
Practice Address - Street 1:22 THE CRESCENT
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042
Practice Address - Country:US
Practice Address - Phone:973-509-8222
Practice Address - Fax:973-509-8228
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI020104122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist