Provider Demographics
NPI:1700184744
Name:ROSEN, JEREMY S (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:S
Last Name:ROSEN
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 1:200 W 79TH ST APT 5C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-6213
Mailing Address - Country:US
Mailing Address - Phone:908-672-3915
Mailing Address - Fax:
Practice Address - Street 1:200 W 79TH ST APT 5C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-6213
Practice Address - Country:US
Practice Address - Phone:908-672-3915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043632-1122300000X
IADDS-10078122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist