MEDICARE: DR. JOHN L. ROTTSCHALK DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019024742	IL

General Provider Information

NPI Number	:	1164560710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN L. ROTTSCHALK DMD

Provider Business Mailing Address
First Line	:	959 LINCOLN HWY
Second Line	:
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-2234
Country	:	US
Telephone Number	:	618-624-3838
Fax Number	:	618-624-4478

Provider Business Practice Location Address
First Line	:	959 LINCOLN HWY
Second Line	:
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-2234
Country	:	US
Telephone Number	:	618-624-3838
Fax Number	:	618-624-4478

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	10/09/2014

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