Provider Demographics
NPI:1134799646
Name:DEROSE, JEREMY DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:DAVID
Last Name:DEROSE
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 1:164 COUNTRY CLUB CIR STE A
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-7502
Mailing Address - Country:US
Mailing Address - Phone:318-639-9559
Mailing Address - Fax:318-639-9560
Practice Address - Street 1:164 COUNTRY CLUB CIR STE A
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-7502
Practice Address - Country:US
Practice Address - Phone:318-639-9559
Practice Address - Fax:318-639-9560
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7248122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA7248OtherLOUISIANA STATE BOARD OF DENTISTRY