Healthcare Provider Details

I. General information

NPI: 1780869891
Provider Name (Legal Business Name): JACK D ROSENBERG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 BROKEN SOUND PKWY 185
BOCA RATON FL
33487-3507
US

IV. Provider business mailing address

951 BROKEN SOUND PKWY 185
BOCA RATON FL
33487-3507
US

V. Phone/Fax

Practice location:
  • Phone: 561-999-9650
  • Fax: 561-998-8340
Mailing address:
  • Phone: 561-999-9650
  • Fax: 561-998-8340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN17726
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: