Provider Demographics
NPI:1578640801
Name:ROOS, ETHAN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:A
Last Name:ROOS
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 1:1326 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:IA
Mailing Address - Zip Code:50211-1344
Mailing Address - Country:US
Mailing Address - Phone:515-981-0444
Mailing Address - Fax:515-981-1450
Practice Address - Street 1:1326 SUNSET DR
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:IA
Practice Address - Zip Code:50211-1344
Practice Address - Country:US
Practice Address - Phone:515-981-0444
Practice Address - Fax:515-981-1450
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA082651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice