Healthcare Provider Details

I. General information

NPI: 1053683037
Provider Name (Legal Business Name): CARL J ROTH OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E OAK ST STE 2C
BOZEMAN MT
59715-2972
US

IV. Provider business mailing address

113 E OAK ST STE 2C
BOZEMAN MT
59715-2972
US

V. Phone/Fax

Practice location:
  • Phone: 406-587-2020
  • Fax: 844-965-9460
Mailing address:
  • Phone: 406-587-2020
  • Fax: 844-965-9460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number675
License Number StateMT

VIII. Authorized Official

Name: DR. CARL J ROTH III
Title or Position: OD/PRESIDENT
Credential: OD
Phone: 406-587-2020