Healthcare Provider Details

I. General information

NPI: 1982627410
Provider Name (Legal Business Name): CHARLES J ROTH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 CERNON ST STE C
VACAVILLE CA
95688-4549
US

IV. Provider business mailing address

412 CERNON ST STE C
VACAVILLE CA
95688-4549
US

V. Phone/Fax

Practice location:
  • Phone: 707-448-5339
  • Fax: 707-447-0956
Mailing address:
  • Phone: 707-448-5339
  • Fax: 707-447-0956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDL 28481
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: