Provider Demographics
NPI:1669537213
Name:DE LA ROSA, REBECCA J (DDS)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:DE LA ROSA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7318 E. U.S. 36
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123
Mailing Address - Country:US
Mailing Address - Phone:317-272-7715
Mailing Address - Fax:317-272-7719
Practice Address - Street 1:7318 E. U.S. 36
Practice Address - Street 2:SUITE 100
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123
Practice Address - Country:US
Practice Address - Phone:317-272-7715
Practice Address - Fax:317-272-7719
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1200-92261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice