Provider Demographics
NPI:1992098651
Name:ROSS, DEREK (DDS)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 PRUDENTIAL DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-8870
Mailing Address - Country:US
Mailing Address - Phone:304-685-3592
Mailing Address - Fax:
Practice Address - Street 1:316 PRUDENTIAL DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-8870
Practice Address - Country:US
Practice Address - Phone:304-685-3592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV39321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice