MEDICARE: DR. KENNETH P ROTTMAN D.D.S.

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	12009645A	IN

General Provider Information

NPI Number	:	1891091161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH P ROTTMAN D.D.S.

Provider Business Mailing Address
First Line	:	2933 LAKE SHORE DR
Second Line	:
City	:	LONG BEACH
State	:	IN
Zip	:	46360-1705
Country	:	US
Telephone Number	:	219-874-1076
Fax Number	:	219-879-8030

Provider Business Practice Location Address
First Line	:	2933 LAKE SHORE DR
Second Line	:
City	:	LONG BEACH
State	:	IN
Zip	:	46360-1705
Country	:	US
Telephone Number	:	219-874-1076
Fax Number	:	219-879-8030

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

Provider Enumeration Date	:	02/04/2011
Last Update Date	:	02/04/2011

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