Healthcare Provider Details

I. General information

NPI: 1144042706
Provider Name (Legal Business Name): JEFFREY ROSETH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2024
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 YGNACIO VALLEY RD
WALNUT CREEK CA
94598-1812
US

IV. Provider business mailing address

965 HYDE ST
SAN FRANCISCO CA
94109-4837
US

V. Phone/Fax

Practice location:
  • Phone: 559-708-2077
  • Fax:
Mailing address:
  • Phone: 559-708-2077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number110852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: