Provider Demographics
NPI:1073853495
Name:DAN ROSEN DDS A PROFFESIONAL CORPORATION
Entity type:Organization
Organization Name:DAN ROSEN DDS A PROFFESIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-907-6736
Mailing Address - Street 1:16542 VENTURA BLVD STE 505
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4576
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16542 VENTURA BLVD STE 505
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4576
Practice Address - Country:US
Practice Address - Phone:818-907-6736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAN ROSEN DDS A PROFFESIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-21
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38742122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6820710001Medicare NSC