Active NPI
Jeremy David Derose, DDS
- Dentist
- Minden, LA
National Provider Identifier
1134799646
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 7248
- 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
- Last updated
- Jun 29, 2021
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 7248 | LA | Primary |
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 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 7248 | Other | LA | LOUISIANA STATE BOARD OF DENTISTRY |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 7248 | LA | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1624838400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1624924800000",
"number": "1134799646",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "164 COUNTRY CLUB CIR STE A",
"city": "MINDEN",
"state": "LA",
"postal_code": "710557502",
"telephone_number": "318-639-9559",
"fax_number": "318-639-9560"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "164 COUNTRY CLUB CIR STE A",
"city": "MINDEN",
"state": "LA",
"postal_code": "710557502",
"telephone_number": "318-639-9559",
"fax_number": "318-639-9560"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DEROSE",
"first_name": "JEREMY",
"middle_name": "DAVID",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2021-06-28",
"last_updated": "2021-06-29",
"certification_date": "2021-06-29",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "LA",
"license": "7248",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "LOUISIANA STATE BOARD OF DENTISTRY",
"identifier": "7248",
"state": "LA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Minden, LA
- Lillian Leigh Berry Davis, APRN, FNP-C
- Tara Davis
- Depaetment of Health and Hospitals (Minden Behavioral Health Clinic)
- Department of Health & Hospitals (Minden Behavioral Health Clinic)
- Department of Health and Hospital
- Kathleen Elisabeth Deville, F.N.P.-C
- Manish Dhawan, MD
- Dialysis Clinic Inc
- Jennifer Dickinson
- Stephanie Johnson Diffey, APRN, FNP-C
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 29, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.