Healthcare Provider Details

I. General information

NPI: 1245073360
Provider Name (Legal Business Name): CAROLINE ROTI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 N GREEN MOUNT RD STE A
O FALLON IL
62269-3484
US

IV. Provider business mailing address

1415 SAINT LOUIS ST
EDWARDSVILLE IL
62025-1311
US

V. Phone/Fax

Practice location:
  • Phone: 618-622-9720
  • Fax:
Mailing address:
  • Phone: 630-418-1184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019035184
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: