Jeremy David Derose, DDS
Individual provider Active NPI Dentist · Minden, LA
NPI 1134799646 · NPPES record last updated Jun 29, 2021
Key facts
- NPI
- 1134799646
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 7248 (LA)
- Practice address
- 164 Country Club Cir Ste a
Minden, LA 71055-7502 - Phone
- (318) 639-9559
- Fax
- (318) 639-9560
- NPI assigned
- Jun 28, 2021
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 7248 | LA | MD | Professional Counselor |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 7248 | LA | Yes |
Addresses
Primary practice location
164 Country Club Cir Ste a
Minden, LA 71055-7502
Mailing address
164 Country Club Cir Ste a
Minden, LA 71055-7502
Phone (318) 639-9559
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 7248 | Other | LA | LOUISIANA STATE BOARD OF DENTISTRY |
Other providers in Minden, LA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 29, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.