Provider Demographics
NPI:1902212640
Name:ROSE, NOELLE (DMD)
Entity Type:Individual
Prefix:
First Name:NOELLE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9330 BEN PRATT/6 MI CYPRESS
Mailing Address - Street 2:#4
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-6502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9330 BEN PRATT/6 MI CYPRESS
Practice Address - Street 2:#4
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-6502
Practice Address - Country:US
Practice Address - Phone:239-690-6723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 21389122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist