Provider Demographics
NPI:1881936607
Name:ROSEN, JACQUELINE GAIL (DDS, MS, PC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:GAIL
Last Name:ROSEN
Suffix:
Gender:F
Credentials:DDS, MS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:355 W DUNDEE RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-3500
Mailing Address - Country:US
Mailing Address - Phone:847-215-9971
Mailing Address - Fax:847-215-9946
Practice Address - Street 1:355 W DUNDEE RD
Practice Address - Street 2:SUITE 215
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-3500
Practice Address - Country:US
Practice Address - Phone:847-215-9971
Practice Address - Fax:847-215-9946
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL210012251223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics