Provider Demographics
NPI:1336298173
Name:ROTHSTEIN, JEROME PHILIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:PHILIP
Last Name:ROTHSTEIN
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 1:943 CESERY BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-5635
Mailing Address - Country:US
Mailing Address - Phone:904-743-5604
Mailing Address - Fax:904-744-1490
Practice Address - Street 1:943 CESERY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5635
Practice Address - Country:US
Practice Address - Phone:904-743-5604
Practice Address - Fax:904-744-1490
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN41571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT85636Medicare UPIN
FL84668Medicare ID - Type Unspecified