Provider Demographics
NPI:1497317465
Name:ROTH, JORDAN AARON (DDS)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:AARON
Last Name:ROTH
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 1:29001 CEDAR RD STE 670
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-6501
Mailing Address - Country:US
Mailing Address - Phone:440-449-5792
Mailing Address - Fax:
Practice Address - Street 1:29001 CEDAR RD STE 670
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-6501
Practice Address - Country:US
Practice Address - Phone:440-449-5792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0247321223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty