Healthcare Provider Details

I. General information

NPI: 1104124080
Provider Name (Legal Business Name): W GREGORY ROSE DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 04/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 EUBANK BLVD NE SUITE 201
ALBUQUERQUE NM
87111-2565
US

IV. Provider business mailing address

4550 EUBANK BLVD NE SUITE 201
ALBUQUERQUE NM
87111-2565
US

V. Phone/Fax

Practice location:
  • Phone: 505-296-5544
  • Fax: 505-296-6918
Mailing address:
  • Phone: 505-296-5544
  • Fax: 505-296-6918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1897
License Number StateNM

VIII. Authorized Official

Name: DR. WILLIAM GREGORY ROSE
Title or Position: BUSINESS OWNER
Credential: DDS
Phone: 505-296-5544