Provider Demographics
NPI:1568685816
Name:ROSE, JOHN W (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:ROSE
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 1:4520 LOWER TERRACE CIR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2563
Mailing Address - Country:US
Mailing Address - Phone:505-299-4431
Mailing Address - Fax:505-291-0265
Practice Address - Street 1:4520 LOWER TERRACE CIR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2563
Practice Address - Country:US
Practice Address - Phone:505-299-4431
Practice Address - Fax:505-291-0265
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM910122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist