Healthcare Provider Details

I. General information

NPI: 1053353334
Provider Name (Legal Business Name): PAUL TODD ROSE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 RAGLAND RD
BECKLEY WV
25801-9721
US

IV. Provider business mailing address

4350 GRANDVIEW RD
BEAVER WV
25813-9107
US

V. Phone/Fax

Practice location:
  • Phone: 304-252-0472
  • Fax: 304-252-1890
Mailing address:
  • Phone: 304-252-0472
  • Fax: 304-252-1890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberWV 3040
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: