Provider Demographics
NPI:1548385461
Name:ROSE, REGINALD F (DMD)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:F
Last Name:ROSE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 COGSWELL AVE
Mailing Address - Street 2:
Mailing Address - City:PELL CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35125-2446
Mailing Address - Country:US
Mailing Address - Phone:205-338-2915
Mailing Address - Fax:
Practice Address - Street 1:402 COGSWELL AVE
Practice Address - Street 2:
Practice Address - City:PELL CITY
Practice Address - State:AL
Practice Address - Zip Code:35125-2446
Practice Address - Country:US
Practice Address - Phone:205-338-2915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3277122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist