Provider Demographics
NPI:1568710754
Name:DE LA ROSA, ANDREW DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:DAVID
Last Name:DE LA ROSA
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:PO BOX 412
Mailing Address - Street 2:
Mailing Address - City:NORTH CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03860-0412
Mailing Address - Country:US
Mailing Address - Phone:561-706-3145
Mailing Address - Fax:
Practice Address - Street 1:2967 WHITE MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860-5111
Practice Address - Country:US
Practice Address - Phone:603-356-2566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH039151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice