# MICHAEL A DEROSE DDS PA

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1457389108
- **Authorized official:** DR. MICHAEL ANTHONY DEROSE DDS (OWNER)
- **Authorized official phone:** (336) 777-0303

## Contact information

- **Practice address:** 3212 S WILMINGTON ST, RALEIGH, NC 27603-3538
- **Practice address phone:** (919) 773-3002
- **Practice address fax:** (919) 773-8824
- **Mailing address:** 2041 SILAS CREEK PKWY, WINSTON SALEM, NC 27103-5147
- **Mailing address phone:** (336) 777-0303
- **Mailing address fax:** (336) 777-3448

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | NULL | Yes |
| 1223G0001X | General Practice Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 06/30/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 012RV | BLUE CROSS BLUE SHIELD NC | — |
| 05 | — | 89012RV | — | NC |