Healthcare Provider Details

I. General information

NPI: 1356389852
Provider Name (Legal Business Name): GERALD ROTHMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 KENMORE AVE SUITE # 204
ALEXANDRIA VA
22304-1313
US

IV. Provider business mailing address

4660 KENMORE AVE SUITE # 204
ALEXANDRIA VA
22304-1313
US

V. Phone/Fax

Practice location:
  • Phone: 703-370-3012
  • Fax: 703-370-6005
Mailing address:
  • Phone: 703-370-3012
  • Fax: 703-370-6005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number05390
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: