Provider Demographics
NPI:1568824241
Name:ANTOSH, ROCHELLE LEE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:ROCHELLE
Middle Name:LEE
Last Name:ANTOSH
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W MORELAND BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2483
Mailing Address - Country:US
Mailing Address - Phone:262-896-9891
Mailing Address - Fax:262-347-4449
Practice Address - Street 1:711 W MORELAND BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2483
Practice Address - Country:US
Practice Address - Phone:262-896-9891
Practice Address - Fax:262-347-4449
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11047-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist