MEDICARE: W GREGORY ROSE DDS PA

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	332BC3200X	Customized Equipment (DME)
2	122300000X	Dentist	DD1897	NM

General Provider Information

NPI Number	:	1104124080
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W GREGORY ROSE DDS PA

Provider Business Mailing Address
First Line	:	4550 EUBANK BLVD NE
Second Line	:	SUITE 201
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-2565
Country	:	US
Telephone Number	:	505-296-5544
Fax Number	:	505-296-6918

Provider Business Practice Location Address
First Line	:	4550 EUBANK BLVD NE
Second Line	:	SUITE 201
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-2565
Country	:	US
Telephone Number	:	505-296-5544
Fax Number	:	505-296-6918

Authorized Official
Title or Position	:	BUSINESS OWNER
Name	:	DR. WILLIAM GREGORY ROSE
Credential	:	DDS
Telephone Number	:	505-296-5544

Provider Enumeration Date	:	03/02/2011
Last Update Date	:	04/26/2011

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