=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356685291
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIN ROSE DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2012
-----------------------------------------------------
Last Update Date | 11/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 906 ROYAL CT
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97504-6139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-414-0519
-----------------------------------------------------
Fax | 541-842-7774
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 E MAIN ST
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97504-7667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-773-3863
-----------------------------------------------------
Fax | 541-500-8171
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number | D11562
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------