=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487736898
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAWRENCE IRA ALAN ROTHENBERG D.D.S., M.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5454 WISCONSIN AVE SUITE #1350
-----------------------------------------------------
City | CHEVY CHASE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20815-6901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-652-1545
-----------------------------------------------------
Fax | 301-652-4171
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5454 WISCONSIN AVE SUITE #1350
-----------------------------------------------------
City | CHEVY CHASE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20815-6901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-652-1545
-----------------------------------------------------
Fax | 301-652-4171
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | MD5547
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------