Provider Demographics
NPI:1932300415
Name:ROSE, RUSSELL (DDS)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:ROSE
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 1:1426 FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3834
Mailing Address - Country:US
Mailing Address - Phone:626-799-2611
Mailing Address - Fax:
Practice Address - Street 1:1426 FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3834
Practice Address - Country:US
Practice Address - Phone:626-799-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice