Provider Demographics
NPI:1861675233
Name:ROSA, PETER A (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:A
Last Name:ROSA
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3304 BELL BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1603
Mailing Address - Country:US
Mailing Address - Phone:718-428-8900
Mailing Address - Fax:
Practice Address - Street 1:3304 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-1603
Practice Address - Country:US
Practice Address - Phone:718-428-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-08
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0506841223S0112X
NY252694204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery