1326255340 NPI number — JEFFREY LEWIS ROTH D.M.D.

Table of content: JEFFREY LEWIS ROTH D.M.D. (NPI 1326255340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326255340 NPI number — JEFFREY LEWIS ROTH D.M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTH
Provider First Name:
JEFFREY
Provider Middle Name:
LEWIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326255340
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
CMR 454
Provider Second Line Business Mailing Address:
BOX 1272
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AE
Provider Business Mailing Address Postal Code:
09250-1272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
015226488826
Provider Business Mailing Address Fax Number:
09082832310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CMR 454
Provider Second Line Business Practice Location Address:
BOX 1272
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09250-1272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
015226488826
Provider Business Practice Location Address Fax Number:
09082832310
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  3542 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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