Healthcare Provider Details

I. General information

NPI: 1255456844
Provider Name (Legal Business Name): DONALD ADAM DEROSA D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 PETERS PL
RED BANK NJ
07701-1705
US

IV. Provider business mailing address

29 PETERS PL
RED BANK NJ
07701-1705
US

V. Phone/Fax

Practice location:
  • Phone: 732-747-7117
  • Fax: 732-741-7679
Mailing address:
  • Phone: 732-747-7117
  • Fax: 732-741-7679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number22D100948400
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: