Provider Demographics
NPI:1902465859
Name:ROSE, DUSTY ELLEN (DMD)
Entity type:Individual
Prefix:DR
First Name:DUSTY
Middle Name:ELLEN
Last Name:ROSE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 N YOUNG BLVD
Mailing Address - Street 2:
Mailing Address - City:CHIEFLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32626-1312
Mailing Address - Country:US
Mailing Address - Phone:352-493-1416
Mailing Address - Fax:
Practice Address - Street 1:723 N YOUNG BLVD
Practice Address - Street 2:
Practice Address - City:CHIEFLAND
Practice Address - State:FL
Practice Address - Zip Code:32626-1312
Practice Address - Country:US
Practice Address - Phone:352-493-1416
Practice Address - Fax:352-493-2057
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN241651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice