Provider Demographics
NPI:1689726457
Name:ROTHENBERG, JEFFREY LANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LANE
Last Name:ROTHENBERG
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 1:179 FOX HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-2512
Mailing Address - Country:US
Mailing Address - Phone:201-689-9432
Mailing Address - Fax:
Practice Address - Street 1:260 GODWIN AVE
Practice Address - Street 2:
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-5200
Practice Address - Country:US
Practice Address - Phone:201-891-8778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ113791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice