Basic Information
| Provider Information | |||||||||
| NPI: | 1164011425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | ROBERTA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIBLEY | ||||||||
| OtherFirstName: | ROBERTA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15735 W US HIGHWAY 63 | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548436475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156342541 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 115 5TH AVE N | ||||||||
| Address2: | |||||||||
| City: | HURLEY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545341208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153291288 | ||||||||
| FaxNumber: | 7153291334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2021 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 1003586 | WI | Y | Dental Providers | Dental Hygienist |
No ID Information.