Healthcare Provider Details

I. General information

NPI: 1871796292
Provider Name (Legal Business Name): PAUL EMILE ROSSOUW DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 ELMWOOD AVE
ROCHESTER NY
14620-2913
US

IV. Provider business mailing address

625 ELMWOOD AVE
ROCHESTER NY
14620-2913
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-5012
  • Fax: 585-273-1233
Mailing address:
  • Phone: 585-275-5012
  • Fax: 585-273-1233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number000057
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: