MEDICARE: KATHLEEN 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	122300000X	Dentist	1354	WI

General Provider Information

NPI Number	:	1235153081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN 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	:	262-334-1230

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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