Provider Demographics
NPI:1780201202
Name:JEROME, ROBERT (DMD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:JEROME
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 WINSTON DR
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-1028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1344 CRESTON PARK DR STE 2
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-1113
Practice Address - Country:US
Practice Address - Phone:608-314-1940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002340-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist