Provider Demographics
NPI:1437713450
Name:ROSE, BROCK D (DMD)
Entity type:Individual
Prefix:DR
First Name:BROCK
Middle Name:D
Last Name:ROSE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 E 300 N
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-2047
Mailing Address - Country:US
Mailing Address - Phone:385-313-4886
Mailing Address - Fax:
Practice Address - Street 1:2240 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-1511
Practice Address - Country:US
Practice Address - Phone:801-393-5355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11258140-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist