Healthcare Provider Details

I. General information

NPI: 1558589739
Provider Name (Legal Business Name): LESLEY GAIL ROTH D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 MAIN ST
SALEM NH
03079-3148
US

IV. Provider business mailing address

220 MAIN ST
SALEM NH
03079-3148
US

V. Phone/Fax

Practice location:
  • Phone: 603-898-1450
  • Fax: 603-893-8751
Mailing address:
  • Phone: 603-898-1450
  • Fax: 603-893-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2278
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: