Provider Demographics
NPI:1083161251
Name:ROSENBOROUGH, JERRETT (DDS)
Entity Type:Individual
Prefix:
First Name:JERRETT
Middle Name:
Last Name:ROSENBOROUGH
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 1:269 E OVILLA RD
Mailing Address - Street 2:300
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-2607
Mailing Address - Country:US
Mailing Address - Phone:972-576-3603
Mailing Address - Fax:
Practice Address - Street 1:269 E OVILLA RD
Practice Address - Street 2:300
Practice Address - City:RED OAK
Practice Address - State:TX
Practice Address - Zip Code:75154-2607
Practice Address - Country:US
Practice Address - Phone:972-576-3603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32355122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist