Healthcare Provider Details

I. General information

NPI: 1649856261
Provider Name (Legal Business Name): ALYSSA F ROSEBOROUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 S VAL VISTA DR STE 164
GILBERT AZ
85295-1680
US

IV. Provider business mailing address

2135 N CHESTNUT CIR
MESA AZ
85213-2206
US

V. Phone/Fax

Practice location:
  • Phone: 480-633-9977
  • Fax:
Mailing address:
  • Phone: 480-766-6853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH009481
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: