Healthcare Provider Details

I. General information

NPI: 1063547545
Provider Name (Legal Business Name): ROSE MARTINE GEDEON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1454 MADISON AVE W
IMMOKALEE FL
34142-2200
US

IV. Provider business mailing address

3415 LAUREL GREENS LN S APT 202
NAPLES FL
34119-7953
US

V. Phone/Fax

Practice location:
  • Phone: 239-658-3030
  • Fax: 800-240-2967
Mailing address:
  • Phone: 239-687-8062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN17804
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: