Provider Demographics
NPI:1225601511
Name:DEROSE, GREGORY JR (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:DEROSE
Suffix:JR
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 1:7223 MISSISSIPPI AVENUE
Mailing Address - Street 2:BLDG 1561
Mailing Address - City:FORT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71459
Mailing Address - Country:US
Mailing Address - Phone:337-531-2603
Mailing Address - Fax:
Practice Address - Street 1:7223 MISSISSIPPI AVENUE
Practice Address - Street 2:BLDG 1561
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459
Practice Address - Country:US
Practice Address - Phone:337-531-2603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4515122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist