Healthcare Provider Details

I. General information

NPI: 1346464583
Provider Name (Legal Business Name): STEPHEN J. ROUSE DMD MS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 S SHARON AMITY RD SUITE #306
CHARLOTTE NC
28211-2978
US

IV. Provider business mailing address

309 S SHARON AMITY RD SUITE #306
CHARLOTTE NC
28211-2978
US

V. Phone/Fax

Practice location:
  • Phone: 704-366-2001
  • Fax: 704-366-4990
Mailing address:
  • Phone: 704-366-2001
  • Fax: 704-366-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number8216
License Number StateNC

VIII. Authorized Official

Name: DR. STEPHEN JAMES ROUSE
Title or Position: MANAGER
Credential: DMD
Phone: 704-366-2001