Provider Demographics
NPI:1780690776
Name:ROSE, MARTINE C (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTINE
Middle Name:C
Last Name:ROSE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 BREMO RD
Mailing Address - Street 2:SUITE 121
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2444
Mailing Address - Country:US
Mailing Address - Phone:804-282-9191
Mailing Address - Fax:
Practice Address - Street 1:2010 BREMO RD
Practice Address - Street 2:SUITE 121
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2444
Practice Address - Country:US
Practice Address - Phone:804-282-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010077411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
146474OtherBLUE CROSS& BLUE SHIELD
172857OtherUNITED CONCORDIA