Provider Demographics
NPI:1366965337
Name:ROSENAU, LANDI JENNIFER (DDS)
Entity type:Individual
Prefix:DR
First Name:LANDI
Middle Name:JENNIFER
Last Name:ROSENAU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:958 MEADOW VISTA DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-5011
Mailing Address - Country:US
Mailing Address - Phone:704-607-1678
Mailing Address - Fax:
Practice Address - Street 1:9456 CHARLOTTE HWY STE 202
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-7953
Practice Address - Country:US
Practice Address - Phone:803-766-7973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-21
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC97981223G0001X
NC108141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10814OtherDENTAL LISENCE
SC9798OtherDENTAL LISENCE