Provider Demographics
NPI:1679683759
Name:ROSE, GEORGE GLENN (DDS DOS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:GLENN
Last Name:ROSE
Suffix:
Gender:M
Credentials:DDS DOS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13
Mailing Address - Street 2:211 LIVE OAK ST
Mailing Address - City:MARLIN
Mailing Address - State:TX
Mailing Address - Zip Code:76661
Mailing Address - Country:US
Mailing Address - Phone:254-883-9225
Mailing Address - Fax:254-883-9326
Practice Address - Street 1:211 LIVE OAK ST
Practice Address - Street 2:
Practice Address - City:MARLIN
Practice Address - State:TX
Practice Address - Zip Code:76661
Practice Address - Country:US
Practice Address - Phone:254-883-9225
Practice Address - Fax:254-883-9326
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX #121441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice