=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376553826
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL J ROTHAN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11430 HAMILTON AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45231-6104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-825-6111
-----------------------------------------------------
Fax | 513-825-5947
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11430 HAMILTON AVE
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45231-6104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-825-6111
-----------------------------------------------------
Fax | 513-825-5947
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 18278
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------