Provider Demographics
NPI:1679790828
Name:JACQUELINE G ROSEN
Entity Type:Organization
Organization Name:JACQUELINE G ROSEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS,PC
Authorized Official - Phone:847-432-1614
Mailing Address - Street 1:1866 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2547
Mailing Address - Country:US
Mailing Address - Phone:847-432-1614
Mailing Address - Fax:
Practice Address - Street 1:1866 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2547
Practice Address - Country:US
Practice Address - Phone:847-432-1614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021-0012251223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty