MEDICARE: DR. TOMMY ROSE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	6742	KS

General Provider Information

NPI Number	:	1003806191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TOMMY ROSE DDS

Provider Business Mailing Address
First Line	:	753 STATE AVE
Second Line	:	STE 402
City	:	KANSAS CITY
State	:	KS
Zip	:	66101-2516
Country	:	US
Telephone Number	:	913-321-3999
Fax Number	:	913-321-5766

Provider Business Practice Location Address
First Line	:	753 STATE AVE
Second Line	:	STE 402
City	:	KANSAS CITY
State	:	KS
Zip	:	66101-2516
Country	:	US
Telephone Number	:	913-321-3999
Fax Number	:	913-321-5766

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	07/08/2007

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