Provider Demographics
NPI:1255456844
Name:DEROSA, DONALD ADAM (DMD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:ADAM
Last Name:DEROSA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 PETERS PL
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1705
Mailing Address - Country:US
Mailing Address - Phone:732-747-7117
Mailing Address - Fax:732-741-7679
Practice Address - Street 1:29 PETERS PL
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1705
Practice Address - Country:US
Practice Address - Phone:732-747-7117
Practice Address - Fax:732-741-7679
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D1009484001223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics