Provider Demographics
NPI:1114199783
Name:DEROSA, THOMAS A (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:DEROSA
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 1:625 ELMWOOD AVENUE
Mailing Address - Street 2:EASTMAN DENTAL CENTER
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-2913
Mailing Address - Country:US
Mailing Address - Phone:585-275-1117
Mailing Address - Fax:
Practice Address - Street 1:625 ELMWOOD AVE
Practice Address - Street 2:EASTMAN DENTAL CENTER
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2913
Practice Address - Country:US
Practice Address - Phone:585-275-1117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-24
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0371221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice