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General NPI Number Information
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NPI Number | 1699976902
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Entity Type | Organization
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Legal Business Name | MARY K. ROTH D.D.S. PC
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Dates
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Enumeration Date | 05/31/2007
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Last Update Date | 06/10/2008
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Provider Practice Location Address
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Address Line | 807 SAINT ANDREW ST
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City | RAPID CITY
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State | SD
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Zip | 57701-4526
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Country | US
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Telephone | 605-343-9352
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Fax | 605-343-3115
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Provider Business Mailing Address
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Address Line | 807 SAINT ANDREW ST
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City | RAPID CITY
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State | SD
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Zip | 57701-4526
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Country | US
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Telephone | 605-343-9352
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Fax | 605-343-3115
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Authorized Official
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Title or Position | DOCTER
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Name | MRS. MARY KAY ROTH
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Credential | D.D.S.
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Telephone | 605-343-9352
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | M697
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License Number State | SD
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