Provider Demographics
NPI:1962194647
Name:ROSE, BRENDA MICHELE (RDH)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:MICHELE
Last Name:ROSE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 HILL PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201-2626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4260 FORT HENRY DR STE 13
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-2248
Practice Address - Country:US
Practice Address - Phone:423-239-6594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402208559124Q00000X
TN10293124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist