Provider Demographics
NPI:1922474519
Name:PROSE, JOELLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOELLE
Middle Name:
Last Name:PROSE
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 1:600 CAISSON HILL RD
Mailing Address - Street 2:U.S. ARMY DENTAL ACTIVITY
Mailing Address - City:FT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-7037
Mailing Address - Country:US
Mailing Address - Phone:785-239-7241
Mailing Address - Fax:
Practice Address - Street 1:618TH DENTAL COMPANY
Practice Address - Street 2:UNIT # 15660, BLDG # P3020
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271-5660
Practice Address - Country:US
Practice Address - Phone:050-050-3337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-18
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021571122300000X
KS61523122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1922474519OtherINSURANCE