Provider Demographics
NPI:1104231497
Name:ROSE, ERIC R (DMD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:R
Last Name:ROSE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 STEWART DR
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-8838
Mailing Address - Country:US
Mailing Address - Phone:509-430-7036
Mailing Address - Fax:
Practice Address - Street 1:5000 W CLEARWATER AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-1910
Practice Address - Country:US
Practice Address - Phone:509-783-5000
Practice Address - Fax:509-783-8349
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60478319122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist