Provider Demographics
NPI:1083029078
Name:ROSE, ROSALYCE LUCILE (RDH)
Entity Type:Individual
Prefix:
First Name:ROSALYCE
Middle Name:LUCILE
Last Name:ROSE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:589 REGENTS PL
Mailing Address - Street 2:
Mailing Address - City:REEDSPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97467-1746
Mailing Address - Country:US
Mailing Address - Phone:541-643-9846
Mailing Address - Fax:
Practice Address - Street 1:1289 WINCHESTER AVE
Practice Address - Street 2:
Practice Address - City:REEDSPORT
Practice Address - State:OR
Practice Address - Zip Code:97467-1373
Practice Address - Country:US
Practice Address - Phone:888-468-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-27
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH1361124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist