MEDICARE: GREGORY DEROSE JR. 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	4515	AR

General Provider Information

NPI Number	:	1225601511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY DEROSE JR. DDS

Provider Business Mailing Address
First Line	:	7223 MISSISSIPPI AVENUE
Second Line	:	BLDG 1561
City	:	FORT POLK
State	:	LA
Zip	:	71459
Country	:	US
Telephone Number	:	337-531-2603
Fax Number	:

Provider Business Practice Location Address
First Line	:	7223 MISSISSIPPI AVENUE
Second Line	:	BLDG 1561
City	:	FORT POLK
State	:	LA
Zip	:	71459
Country	:	US
Telephone Number	:	337-531-2603
Fax Number	:

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

Provider Enumeration Date	:	07/23/2021
Last Update Date	:	07/23/2021

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