Provider Demographics
NPI:1124067665
Name:ROSENSON, JACK ALAN (DMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:ALAN
Last Name:ROSENSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13859 CARMEL VALLEY RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-5665
Mailing Address - Country:US
Mailing Address - Phone:858-484-9090
Mailing Address - Fax:858-484-9211
Practice Address - Street 1:13859 CARMEL VALLEY RD
Practice Address - Street 2:SUITE D
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-5665
Practice Address - Country:US
Practice Address - Phone:858-484-9090
Practice Address - Fax:858-484-9211
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA371571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice