Provider Demographics
NPI:1710109210
Name:ROSE FAMILY DENTAL
Entity Type:Organization
Organization Name:ROSE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-687-5665
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:15 SW 20TH AVENUE
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604
Mailing Address - Country:US
Mailing Address - Phone:360-687-5665
Mailing Address - Fax:360-687-5053
Practice Address - Street 1:15 SW 20TH AVENUE
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604
Practice Address - Country:US
Practice Address - Phone:360-687-5665
Practice Address - Fax:360-687-5053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA9791122300000X
WA4539122300000X
WA7107122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty