Healthcare Provider Details

I. General information

NPI: 1861675233
Provider Name (Legal Business Name): PETER A ROSA MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2007
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3304 BELL BLVD
BAYSIDE NY
11361-1603
US

IV. Provider business mailing address

3304 BELL BLVD
BAYSIDE NY
11361-1603
US

V. Phone/Fax

Practice location:
  • Phone: 718-428-8900
  • Fax:
Mailing address:
  • Phone: 718-428-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number050684
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number252694
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: