Provider Demographics
NPI:1972209773
Name:MCCAULEY, ROSE
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:MCCAULEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1512
Mailing Address - Country:US
Mailing Address - Phone:570-430-1964
Mailing Address - Fax:
Practice Address - Street 1:959 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18509-3023
Practice Address - Country:US
Practice Address - Phone:570-344-9684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH007514L124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist