Provider Demographics
NPI:1104124080
Name:W GREGORY ROSE DDS PA
Entity type:Organization
Organization Name:W GREGORY ROSE DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-296-5544
Mailing Address - Street 1:4550 EUBANK BLVD NE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2565
Mailing Address - Country:US
Mailing Address - Phone:505-296-5544
Mailing Address - Fax:505-296-6918
Practice Address - Street 1:4550 EUBANK BLVD NE
Practice Address - Street 2:SUITE 201
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2565
Practice Address - Country:US
Practice Address - Phone:505-296-5544
Practice Address - Fax:505-296-6918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-02
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
NMDD1897122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM6499880001Medicare NSC