Provider Demographics
NPI:1508093386
Name:ROSENGREN, ERIC BRUCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:BRUCE
Last Name:ROSENGREN
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 1:24722 104TH AVE SE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-5322
Mailing Address - Country:US
Mailing Address - Phone:253-859-0123
Mailing Address - Fax:253-859-5864
Practice Address - Street 1:24722 104TH AVE SE
Practice Address - Street 2:SUITE 201
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-5322
Practice Address - Country:US
Practice Address - Phone:253-859-0123
Practice Address - Fax:253-859-5864
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE602694251223G0001X
KS607581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200632500AMedicaid