Provider Demographics
NPI:1144347303
Name:JACQUELINE G ROSEN
Entity type:Organization
Organization Name:JACQUELINE G ROSEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDSMSPC
Authorized Official - Phone:847-215-9971
Mailing Address - Street 1:355 W DUNDEE RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-3500
Mailing Address - Country:US
Mailing Address - Phone:847-215-9971
Mailing Address - Fax:847-215-9946
Practice Address - Street 1:355 W DUNDEE RD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-3500
Practice Address - Country:US
Practice Address - Phone:847-215-9971
Practice Address - Fax:847-215-9946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID