Provider Demographics
NPI:1073642443
Name:GONZALES-MUGABURU, ROSE BETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROSE
Middle Name:BETH
Last Name:GONZALES-MUGABURU
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 1:3108 HERDSMAN WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-7582
Mailing Address - Country:US
Mailing Address - Phone:919-570-9025
Mailing Address - Fax:
Practice Address - Street 1:3108 HERDSMAN WAY
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-7582
Practice Address - Country:US
Practice Address - Phone:919-570-9025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC74351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89902W2Medicaid