Provider Demographics
NPI:1174665798
Name:ROSSA, JOSEPH W (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:W
Last Name:ROSSA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1272
Mailing Address - Country:US
Mailing Address - Phone:773-763-6836
Mailing Address - Fax:773-775-4431
Practice Address - Street 1:5400 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-1272
Practice Address - Country:US
Practice Address - Phone:773-763-6836
Practice Address - Fax:773-775-4431
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019A127781223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT37116Medicare UPIN
IL525020Medicare ID - Type Unspecified