Provider Demographics
NPI:1164011425
Name:ROSS, ROBERTA (RDH)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:
Other - Last Name:SIBLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15735 W US HIGHWAY 63
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-6475
Mailing Address - Country:US
Mailing Address - Phone:715-634-2541
Mailing Address - Fax:
Practice Address - Street 1:115 5TH AVE N
Practice Address - Street 2:
Practice Address - City:HURLEY
Practice Address - State:WI
Practice Address - Zip Code:54534-1208
Practice Address - Country:US
Practice Address - Phone:715-329-1288
Practice Address - Fax:715-329-1334
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1003586124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist