Provider Demographics
NPI:1962462705
Name:KRASAVAGE, ROSA MARIA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:ROSA
Middle Name:MARIA
Last Name:KRASAVAGE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ROSA
Other - Middle Name:MARIA
Other - Last Name:LOPEZ SALAZAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13706 W BELL RD
Mailing Address - Street 2:STE 2
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374
Mailing Address - Country:US
Mailing Address - Phone:623-584-9910
Mailing Address - Fax:623-584-9940
Practice Address - Street 1:13706 W BELL RD
Practice Address - Street 2:STE 2
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374
Practice Address - Country:US
Practice Address - Phone:623-584-9910
Practice Address - Fax:623-584-9940
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD4518122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ310178Medicaid