Healthcare Provider Details

I. General information

NPI: 1982626826
Provider Name (Legal Business Name): DONALD PERRIN ROTEN SR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 UNION ST
RIPLEY MS
38663-1718
US

IV. Provider business mailing address

307 UNION ST
RIPLEY MS
38663-1718
US

V. Phone/Fax

Practice location:
  • Phone: 662-837-4664
  • Fax: 662-837-1501
Mailing address:
  • Phone: 662-837-4664
  • Fax: 662-837-1501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberMS1279-67
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: