Provider Demographics
NPI:1710274246
Name:DELA ROSA, RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:DELA ROSA
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 1:44 FITZGERALD LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NJ
Mailing Address - Zip Code:08022-2387
Mailing Address - Country:US
Mailing Address - Phone:415-505-7164
Mailing Address - Fax:
Practice Address - Street 1:4 PROGRESS ST
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1199
Practice Address - Country:US
Practice Address - Phone:908-757-3191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY05629811223P0221X
NJ22DI024939001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program