Healthcare Provider Details

I. General information

NPI: 1568970010
Provider Name (Legal Business Name): ROGELIO DE LA ROSA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 SE WILLOUGHBY BLVD
STUART FL
34994-5059
US

IV. Provider business mailing address

3509 SE WILLOUGHBY BLVD
STUART FL
34994-5059
US

V. Phone/Fax

Practice location:
  • Phone: 772-220-2990
  • Fax:
Mailing address:
  • Phone: 727-394-6064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN22903
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: