Provider Demographics
NPI:1598867806
Name:ROSE, DANIEL EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:EDWARD
Last Name:ROSE
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 1:6006 84TH ST SW
Mailing Address - Street 2:
Mailing Address - City:MOTLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56466-2128
Mailing Address - Country:US
Mailing Address - Phone:218-397-2341
Mailing Address - Fax:
Practice Address - Street 1:1401 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:COUSHATTA
Practice Address - State:LA
Practice Address - Zip Code:71019
Practice Address - Country:US
Practice Address - Phone:318-932-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA72911223G0001X
MND87091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN802518500Medicaid