Provider Demographics
NPI:1053353334
Name:ROSE, PAUL TODD (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:TODD
Last Name:ROSE
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 1:4350 GRANDVIEW RD
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:WV
Mailing Address - Zip Code:25813-9107
Mailing Address - Country:US
Mailing Address - Phone:304-252-0472
Mailing Address - Fax:304-252-1890
Practice Address - Street 1:220 RAGLAND RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-9721
Practice Address - Country:US
Practice Address - Phone:304-252-0472
Practice Address - Fax:304-252-1890
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV 30401223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0133045001Medicaid