MEDICARE: DR. JASON A ROTH DDS

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	122300000X	Dentist	52922	CA

General Provider Information

NPI Number	:	1841380920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON A ROTH DDS

Provider Business Mailing Address
First Line	:	PO BOX 5465
Second Line	:
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-0009
Country	:	US
Telephone Number	:	916-213-4255
Fax Number	:

Provider Business Practice Location Address
First Line	:	4517 SERRANO PARKWAY
Second Line	:	SUITE 101
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762
Country	:	US
Telephone Number	:	916-939-9999
Fax Number	:

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	09/04/2012

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