Individual
MICHAEL ANTHONY DEROSE
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Contact information
Practice address
1022 LIBERTY LN, PUEBLO, CO 81001-2039
(719) 545-5778
Mailing address
415 N GRAND AVE, PUEBLO, CO 81003-3111
(719) 546-3333
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
12010424A
IN
1223G0001X
General Practice Dentistry
5643
OK
1223G0001X
General Practice Dentistry
60184
KS
1223G0001X
General Practice Dentistry
DD2030
NM
1223G0001X
General Practice Dentistry
Primary
DEN-5133
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2051332
—
CO
Enumeration date
02/23/2006
Last updated
07/09/2007
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