Provider Demographics
NPI:1669732897
Name:ROSENGREN FAMILY DENTAL GROUP, INC.
Entity type:Organization
Organization Name:ROSENGREN FAMILY DENTAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:ROSENGREN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-859-0123
Mailing Address - Street 1:24722 104TH AVE SE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-5322
Mailing Address - Country:US
Mailing Address - Phone:253-859-0123
Mailing Address - Fax:253-859-5864
Practice Address - Street 1:24722 104TH AVE SE
Practice Address - Street 2:SUITE 201
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-5322
Practice Address - Country:US
Practice Address - Phone:253-859-0123
Practice Address - Fax:253-859-5864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE602694251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty