Provider Demographics
NPI:1053972646
Name:ROSS, JATERRA DOMINIQUE (DMD)
Entity type:Individual
Prefix:DR
First Name:JATERRA
Middle Name:DOMINIQUE
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 1:7407 CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-2710
Mailing Address - Country:US
Mailing Address - Phone:847-404-7029
Mailing Address - Fax:
Practice Address - Street 1:12300 DORSETT RD
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-3906
Practice Address - Country:US
Practice Address - Phone:314-254-4000
Practice Address - Fax:314-732-1826
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019021855122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist