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Organization
BALLANCE & DEROSE DDS PA
Active
Organization
BALLANCE & DEROSE DDS PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MICHAEL ANTHONY DEROSE DDS (OWNER)
(336) 777-0303
Entity
Organization
Contact information
Practice address
1400 WALTER REED RD, SUITE 200, FAYETTEVILLE, NC 28304-4409
(910) 864-9884
Mailing address
2041 SILAS CREEK PKWY, WINSTON SALEM, NC 27103-5147
(336) 777-0303
(336) 777-3448
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
NULL
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
018C1
BLUE CROSS BLUE SHIELD NC
—
01
—
1945717
UNITED CONCORDIA
—
05
—
5903665
—
NC
Enumeration date
07/08/2006
Last updated
08/22/2020
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