MEDICARE: DR. JACK ALAN ROSENSON D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	37157	CA

General Provider Information

NPI Number	:	1124067665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK ALAN ROSENSON D.M.D.

Provider Business Mailing Address
First Line	:	13859 CARMEL VALLEY RD
Second Line	:	SUITE D
City	:	SAN DIEGO
State	:	CA
Zip	:	92130-5665
Country	:	US
Telephone Number	:	858-484-9090
Fax Number	:	858-484-9211

Provider Business Practice Location Address
First Line	:	13859 CARMEL VALLEY RD
Second Line	:	SUITE D
City	:	SAN DIEGO
State	:	CA
Zip	:	92130-5665
Country	:	US
Telephone Number	:	858-484-9090
Fax Number	:	858-484-9211

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	07/08/2007

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