MEDICARE: DR. TIMOTHY BRODERICK ROETS 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	049634	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093809345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY BRODERICK ROETS D.M.D.

Provider Business Mailing Address
First Line	:	92 ELM ST
Second Line	:
City	:	WESTFIELD
State	:	NY
Zip	:	14787-1436
Country	:	US
Telephone Number	:	716-326-2232
Fax Number	:	716-326-2236

Provider Business Practice Location Address
First Line	:	92 ELM ST
Second Line	:
City	:	WESTFIELD
State	:	NY
Zip	:	14787-1436
Country	:	US
Telephone Number	:	716-326-2232
Fax Number	:	716-326-2236

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/09/2007

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