Provider Demographics
NPI:1104827930
Name:ROTH, JUSTIN LEE (DDS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LEE
Last Name:ROTH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5929 CONSTITUTION AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-1211
Mailing Address - Country:US
Mailing Address - Phone:719-638-1986
Mailing Address - Fax:719-638-7532
Practice Address - Street 1:5929 CONSTITUTION AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-1211
Practice Address - Country:US
Practice Address - Phone:719-638-1986
Practice Address - Fax:719-638-7532
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3407122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist