Provider Demographics
NPI:1144399189
Name:ROTH, JEFFREY R (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:ROTH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:408 SOUTH MAIN STREET, SUITE 1
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-0727
Mailing Address - Country:US
Mailing Address - Phone:208-788-7766
Mailing Address - Fax:208-788-9920
Practice Address - Street 1:408 S MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8402
Practice Address - Country:US
Practice Address - Phone:208-788-7766
Practice Address - Fax:208-788-9920
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD37781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806932600Medicaid