Healthcare Provider Details

I. General information

NPI: 1831427335
Provider Name (Legal Business Name): JOHN M. ROSE, D.D.S., M.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2009
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 LARRY POWER RD
BOURBONNAIS IL
60914-5184
US

IV. Provider business mailing address

376 LARRY POWER RD
BOURBONNAIS IL
60914-5184
US

V. Phone/Fax

Practice location:
  • Phone: 815-802-1217
  • Fax: 815-802-1252
Mailing address:
  • Phone: 815-802-1217
  • Fax: 815-802-1252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. JOHN M. ROSE
Title or Position: ORTHODONTIST
Credential: D.D.S., M.S.
Phone: 815-802-1217