MEDICARE: DANIEL H ROTH DDS

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	1223P0700X	Prosthodontics	1343	WI

General Provider Information

NPI Number	:	1205863099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL H ROTH DDS

Provider Business Mailing Address
First Line	:	509 SUMMIT DR
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53095-3853
Country	:	US
Telephone Number	:	262-334-5249
Fax Number	:

Provider Business Practice Location Address
First Line	:	1713 VOGT DR
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53095-8516
Country	:	US
Telephone Number	:	262-334-3070
Fax Number	:

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

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	07/08/2007

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