Provider Demographics
NPI:1598700775
Name:MICHAEL A DEROSE DDS PA
Entity Type:Organization
Organization Name:MICHAEL A DEROSE DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DEROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-777-0303
Mailing Address - Street 1:2041 SILAS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5147
Mailing Address - Country:US
Mailing Address - Phone:336-777-0303
Mailing Address - Fax:336-777-3448
Practice Address - Street 1:4901 N TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-7033
Practice Address - Country:US
Practice Address - Phone:704-921-0204
Practice Address - Fax:704-921-4095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89014NGMedicaid
014NGOtherBLUE CROSS BLUE SHIELD NC