Provider Demographics
NPI:1457396996
Name:ROSA, DON K (DDS)
Entity type:Individual
Prefix:DR
First Name:DON
Middle Name:K
Last Name:ROSA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:603 HOSPITAL DR
Mailing Address - Street 2:SUITE #2
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2914
Mailing Address - Country:US
Mailing Address - Phone:870-425-5955
Mailing Address - Fax:870-425-5955
Practice Address - Street 1:603 HOSPITAL DR
Practice Address - Street 2:SUITE #2
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2914
Practice Address - Country:US
Practice Address - Phone:870-425-5955
Practice Address - Fax:870-425-5955
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR18531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR134237608Medicaid