Healthcare Provider Details

I. General information

NPI: 1295726925
Provider Name (Legal Business Name): RICHARD J. ROOTS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 E LAKE ST
LAKE MILLS WI
53551-1659
US

IV. Provider business mailing address

140 E LAKE ST
LAKE MILLS WI
53551-1659
US

V. Phone/Fax

Practice location:
  • Phone: 920-648-8254
  • Fax: 920-648-3655
Mailing address:
  • Phone: 920-648-8254
  • Fax: 920-648-3655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5001379WI
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: