Healthcare Provider Details

I. General information

NPI: 1205863099
Provider Name (Legal Business Name): DANIEL H ROTH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713 VOGT DR
WEST BEND WI
53095-8516
US

IV. Provider business mailing address

509 SUMMIT DR
WEST BEND WI
53095-3853
US

V. Phone/Fax

Practice location:
  • Phone: 262-334-3070
  • Fax:
Mailing address:
  • Phone: 262-334-5249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number1343
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: