Healthcare Provider Details

I. General information

NPI: 1477902971
Provider Name (Legal Business Name): ZACHARY ROSE L.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 OAK ST
EUGENE OR
97401-3519
US

IV. Provider business mailing address

1241 OAK ST
EUGENE OR
97401-3519
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-9897
  • Fax: 541-485-3505
Mailing address:
  • Phone: 541-686-9897
  • Fax: 541-485-3505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number10176641
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: