Provider Demographics
NPI:1831427335
Name:JOHN M. ROSE, D.D.S., M.S.
Entity type:Organization
Organization Name:JOHN M. ROSE, D.D.S., M.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:815-802-1217
Mailing Address - Street 1:376 LARRY POWER RD
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-5184
Mailing Address - Country:US
Mailing Address - Phone:815-802-1217
Mailing Address - Fax:815-802-1252
Practice Address - Street 1:376 LARRY POWER RD
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-5184
Practice Address - Country:US
Practice Address - Phone:815-802-1217
Practice Address - Fax:815-802-1252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-23
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty