Provider Demographics
NPI:1083748842
Name:ROSE, BEVERLY ANN (DMD, P A)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:ANN
Last Name:ROSE
Suffix:
Gender:F
Credentials:DMD, P A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4360 WINDOVER WAY
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-8517
Mailing Address - Country:US
Mailing Address - Phone:321-259-4666
Mailing Address - Fax:321-259-3295
Practice Address - Street 1:2755 N. WICKHAM RD.
Practice Address - Street 2:SUITE 101
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935
Practice Address - Country:US
Practice Address - Phone:321-259-4666
Practice Address - Fax:321-259-3295
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN143691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice