MEDICARE: KLEA ROTA 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	6000028-15	WI

General Provider Information

NPI Number	:	1245971977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KLEA ROTA DDS

Provider Business Mailing Address
First Line	:	3900 N BAY DR
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53402-3632
Country	:	US
Telephone Number	:	262-639-1600
Fax Number	:

Provider Business Practice Location Address
First Line	:	3900 N BAY DR
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53402-3632
Country	:	US
Telephone Number	:	262-639-1600
Fax Number	:

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

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	01/08/2026

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