Provider Demographics
NPI:1598117632
Name:JAY L. ROSENHECK DDS PC
Entity type:Organization
Organization Name:JAY L. ROSENHECK DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSENHECK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-614-4666
Mailing Address - Street 1:1000 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6737
Mailing Address - Country:US
Mailing Address - Phone:770-614-4666
Mailing Address - Fax:678-279-5533
Practice Address - Street 1:1000 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 10
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6737
Practice Address - Country:US
Practice Address - Phone:770-614-4666
Practice Address - Fax:678-279-5533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7575330001Medicare NSC