Active NPI
Gregg Lee Rose, DDS
- Pediatric Dentistry
- Champaign, IL
National Provider Identifier
1730243171
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- 021.001507019.021040
- Practice address
- 1715 Broadmoor Dr
Suite B
Champaign, IL 61821-5983 - Phone
- (217) 352-7337
- NPI assigned
- Dec 20, 2006
- 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 |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | 021.001507019.021040 | IL | Primary |
Addresses
Primary practice location
1715 Broadmoor Dr
Suite B
Champaign, IL 61821-5983
Mailing address
1715 Broadmoor Dr
Suite B
Champaign, IL 61821-5983
Phone (217) 352-7337
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 |
|---|---|---|---|
| 021.001507019.021040 | IL | MD | Pediatric Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1166572800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1730243171",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1715 BROADMOOR DR",
"address_2": "SUITE B",
"city": "CHAMPAIGN",
"state": "IL",
"postal_code": "618215983",
"telephone_number": "217-352-7337"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1715 BROADMOOR DR",
"address_2": "SUITE B",
"city": "CHAMPAIGN",
"state": "IL",
"postal_code": "618215983",
"telephone_number": "217-352-7337"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ROSE",
"first_name": "GREGG",
"middle_name": "LEE",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-12-20",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "IL",
"license": "021.001507019.021040",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Champaign, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.