Provider Demographics
NPI:1841380920
Name:ROTH, JASON A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:A
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:PO BOX 5465
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-0009
Mailing Address - Country:US
Mailing Address - Phone:916-213-4255
Mailing Address - Fax:
Practice Address - Street 1:4517 SERRANO PARKWAY
Practice Address - Street 2:SUITE 101
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762
Practice Address - Country:US
Practice Address - Phone:916-939-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist