Provider Demographics
NPI:1326255340
Name:ROTH, JEFFREY LEWIS (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEWIS
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:CMR 454
Mailing Address - Street 2:BOX 1272
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09250-1272
Mailing Address - Country:US
Mailing Address - Phone:01522-648-8826
Mailing Address - Fax:0908-283-2310
Practice Address - Street 1:CMR 454
Practice Address - Street 2:BOX 1272
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09250-1272
Practice Address - Country:US
Practice Address - Phone:01522-648-8826
Practice Address - Fax:0908-283-2310
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3542122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist