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Individual

JEFFREY R ROTH

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man
Credential
DMD

Contact information

Practice address
408 S MAIN ST STE 1, HAILEY, ID 83333-8402
(208) 788-7766
(208) 788-9920
Mailing address
PO BOX 727, 408 SOUTH MAIN STREET, SUITE 1, HAILEY, ID 83333-0727
(208) 788-7766
(208) 788-9920

Taxonomy

Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D3778
ID

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
806932600
ID
Enumeration date
11/06/2006
Last updated
10/19/2010
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