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General NPI Number Information
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NPI Number | 1104837111
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Entity Type | Individual
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Provider Name | KELLY ANN ROTH D.D.S.
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Gender | Female
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Dates
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Enumeration Date | 08/11/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1515 PORTAGE ST NW SUITE I
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City | NORTH CANTON
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State | OH
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Zip | 44720-2290
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Country | US
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Telephone | 330-494-0646
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Fax | 330-494-9181
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Provider Business Mailing Address
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Address Line | 7077 PEBBLESTONE AVE NW
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City | NORTH CANTON
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State | OH
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Zip | 44720-6679
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Country | US
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Telephone | 330-433-9070
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 20709
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License Number State | OH
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