Provider Demographics
NPI:1053456228
Name:ROSOV, THEODORE J (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:J
Last Name:ROSOV
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4326 SW 94TH DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608
Mailing Address - Country:US
Mailing Address - Phone:352-376-1933
Mailing Address - Fax:352-376-0050
Practice Address - Street 1:4965 NW 8TH AVE
Practice Address - Street 2:STE B
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605
Practice Address - Country:US
Practice Address - Phone:352-372-1966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN27751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice