Provider Demographics
NPI:1043411994
Name:ROTH, MESA (DDS)
Entity Type:Individual
Prefix:
First Name:MESA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MESA
Other - Middle Name:
Other - Last Name:ULWELLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2930 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-1011
Mailing Address - Country:US
Mailing Address - Phone:970-353-9403
Mailing Address - Fax:970-353-9906
Practice Address - Street 1:1006 A ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-2021
Practice Address - Country:US
Practice Address - Phone:970-352-0048
Practice Address - Fax:970-352-1120
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9286122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11379766Medicaid