Provider Demographics
NPI:1639362148
Name:ROSENBERG, JACK J (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:J
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6045 BURKE CENTRE PKWY
Mailing Address - Street 2:#202
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-3751
Mailing Address - Country:US
Mailing Address - Phone:703-250-2208
Mailing Address - Fax:703-250-5337
Practice Address - Street 1:6045 BURKE CENTRE PKWY
Practice Address - Street 2:#202
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-3751
Practice Address - Country:US
Practice Address - Phone:703-250-2208
Practice Address - Fax:703-250-5337
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA35341223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics