Healthcare Provider Details

I. General information

NPI: 1912063025
Provider Name (Legal Business Name): KEITH STEVEN ROTTMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2007
Last Update Date: 12/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8140 SECOR RD
LAMBERTVILLE MI
48144-8673
US

IV. Provider business mailing address

8140 SECOR RD
LAMBERTVILLE MI
48144-8673
US

V. Phone/Fax

Practice location:
  • Phone: 734-854-2685
  • Fax: 734-854-2687
Mailing address:
  • Phone: 734-854-2685
  • Fax: 734-854-2687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30017878
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901013501
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019018808
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: