Healthcare Provider Details

I. General information

NPI: 1639268519
Provider Name (Legal Business Name): MARK I ROSENBERG D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2819 ORCHARD LAKE RD
KEEGO HARBOR MI
48320-1448
US

IV. Provider business mailing address

2819 ORCHARD LAKE RD
KEEGO HARBOR MI
48320-1448
US

V. Phone/Fax

Practice location:
  • Phone: 248-683-2323
  • Fax: 248-683-0051
Mailing address:
  • Phone: 248-683-2323
  • Fax: 248-683-0051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12148
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: