Provider Demographics
NPI:1568970010
Name:DE LA ROSA, ROGELIO (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROGELIO
Middle Name:
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 1:3509 SE WILLOUGHBY BLVD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-5059
Mailing Address - Country:US
Mailing Address - Phone:727-394-6064
Mailing Address - Fax:
Practice Address - Street 1:3509 SE WILLOUGHBY BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-5059
Practice Address - Country:US
Practice Address - Phone:772-220-2990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN22903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist