Provider Demographics
NPI:1528147493
Name:ROSA, EDWIN A (DMD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:A
Last Name:ROSA
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:PO BOX 70344
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-8344
Mailing Address - Country:US
Mailing Address - Phone:787-915-3015
Mailing Address - Fax:787-915-3635
Practice Address - Street 1:CARR 2 KM 29.3
Practice Address - Street 2:PARCELAS CARMEN
Practice Address - City:VEGA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00692
Practice Address - Country:US
Practice Address - Phone:787-915-3015
Practice Address - Fax:787-915-3635
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRD25371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice