Provider Demographics
NPI:1356540645
Name:ANTROBUS, JARED B (DDS)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:B
Last Name:ANTROBUS
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 1:6000 FAIRWAY DR STE 10
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-4245
Mailing Address - Country:US
Mailing Address - Phone:916-632-5809
Mailing Address - Fax:
Practice Address - Street 1:6000 FAIRWAY DR STE 10
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-4245
Practice Address - Country:US
Practice Address - Phone:916-632-5809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS622621223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SWMC-258-XOtherINSTITUTIONAL PERMIT