Provider Demographics
NPI:1891490918
Name:LOPER, ROSETTA (CRDH)
Entity Type:Individual
Prefix:
First Name:ROSETTA
Middle Name:
Last Name:LOPER
Suffix:
Gender:F
Credentials:CRDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DAVID GRANT MEDICAL CENTER
Mailing Address - Street 2:151 BODIN CIRCLE
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94535
Mailing Address - Country:US
Mailing Address - Phone:707-423-7000
Mailing Address - Fax:
Practice Address - Street 1:136 CANNON DR
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1132
Practice Address - Country:US
Practice Address - Phone:210-428-9752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH22364124Q00000X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No171000000XOther Service ProvidersMilitary Health Care Provider