Provider Demographics
NPI:1639261787
Name:ROTHROCK, JERRY G (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:G
Last Name:ROTHROCK
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 1:653 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:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0382301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice