Provider Demographics
NPI:1487787925
Name:ROTELLA, JERRY JASON (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:JASON
Last Name:ROTELLA
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 1:8974 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-1114
Mailing Address - Country:US
Mailing Address - Phone:513-683-5405
Mailing Address - Fax:513-683-0405
Practice Address - Street 1:8974 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:OH
Practice Address - Zip Code:45140-1114
Practice Address - Country:US
Practice Address - Phone:513-683-5405
Practice Address - Fax:513-683-0405
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH179661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH17966OtherSTATE DENTAL LICENSE NUMB