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General NPI Number Information
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NPI Number | 1376683698
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Entity Type | Individual
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Provider Name | HEIDI M. ROTH
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Gender | Female
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Dates
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Enumeration Date | 02/07/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | S2845 WHITE EAGLE RD
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City | BARABOO
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State | WI
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Zip | 53913-9064
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Country | US
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Telephone | 608-355-1240
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Fax |
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Provider Business Mailing Address
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Address Line | W8595 BILKIE RD
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City | POYNETTE
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State | WI
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Zip | 53955-9774
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Country | US
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Telephone | 608-635-7663
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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 | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 4219-016
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License Number State | WI
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