Provider Demographics
NPI:1437169505
Name:ROSEBERY, ROBERT A (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:ROSEBERY
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 1:62 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:MI
Mailing Address - Zip Code:49345-1138
Mailing Address - Country:US
Mailing Address - Phone:616-887-7355
Mailing Address - Fax:616-887-2005
Practice Address - Street 1:62 N UNION ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MI
Practice Address - Zip Code:49345-1138
Practice Address - Country:US
Practice Address - Phone:616-887-7355
Practice Address - Fax:616-887-2005
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901009880122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4005391Medicaid