Provider Demographics
NPI:1366482796
Name:ROTHMAN, JEFFREY ROSS
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ROSS
Last Name:ROTHMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 KENMORE AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1313
Mailing Address - Country:US
Mailing Address - Phone:703-370-3012
Mailing Address - Fax:
Practice Address - Street 1:4660 KENMORE AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1313
Practice Address - Country:US
Practice Address - Phone:703-370-3012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014104501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00B991G01Medicare ID - Type Unspecified