Provider Demographics
NPI:1043207046
Name:ROTTER, BRUCE E (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:E
Last Name:ROTTER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 CRYSTAL GATE LN
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1141
Mailing Address - Country:US
Mailing Address - Phone:618-288-0962
Mailing Address - Fax:
Practice Address - Street 1:132 CRYSTAL GATE LN
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1141
Practice Address - Country:US
Practice Address - Phone:618-288-0962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-018159122300000X
IL021-0016421223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL480442OtherHEALTHLINK INS PROV ID
IL1420102OtherUNITED CONCORDIA PROV ID
IL480442OtherHEALTHLINK INS PROV ID
ILL92149Medicare PIN
IL190010592Medicare PIN