MEDICARE: DR. LUIS MIGUEL DE LA ROSA 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	30.028382	OH

General Provider Information

NPI Number	:	1013607738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUIS MIGUEL DE LA ROSA DDS

Provider Business Mailing Address
First Line	:	PO BOX 241272
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-8872
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4071 LEE RD SUITE 260
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128
Country	:	US
Telephone Number	:	216-727-0234
Fax Number	:

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

Provider Enumeration Date	:	05/08/2023
Last Update Date	:	04/30/2026

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