Provider Demographics
NPI:1215029384
Name:JERRY G. ROTHROCK
Entity Type:Organization
Organization Name:JERRY G. ROTHROCK
Other - Org Name:LIVERPOOL DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTHROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-457-4054
Mailing Address - Street 1:653 OLD LIVERPOOL RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-6032
Mailing Address - Country:US
Mailing Address - Phone:315-457-4054
Mailing Address - Fax:315-453-8059
Practice Address - Street 1:653 OLD LIVERPOOL RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6032
Practice Address - Country:US
Practice Address - Phone:315-457-4054
Practice Address - Fax:315-453-8059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0382301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty