Provider Demographics
NPI:1093809345
Name:ROETS, TIMOTHY BRODERICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:BRODERICK
Last Name:ROETS
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 1:92 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14787-1436
Mailing Address - Country:US
Mailing Address - Phone:716-326-2232
Mailing Address - Fax:716-326-2236
Practice Address - Street 1:92 ELM ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NY
Practice Address - Zip Code:14787-1436
Practice Address - Country:US
Practice Address - Phone:716-326-2232
Practice Address - Fax:716-326-2236
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0496341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02208693Medicaid