Provider Demographics
NPI:1629563119
Name:ROUTH, JANNA C (DMD)
Entity type:Individual
Prefix:
First Name:JANNA
Middle Name:C
Last Name:ROUTH
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 OLD SMIZER MILL RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-3538
Mailing Address - Country:US
Mailing Address - Phone:636-326-7633
Mailing Address - Fax:636-600-1229
Practice Address - Street 1:1205 BOLL WEEVIL CIR
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-1377
Practice Address - Country:US
Practice Address - Phone:334-347-9564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180184481223G0001X, 122300000X
ALD.007264-C1223G0001X
GADN1232631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice