Provider Demographics
NPI:1164560710
Name:ROTTSCHALK, JOHN L (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:ROTTSCHALK
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 1:959 LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2234
Mailing Address - Country:US
Mailing Address - Phone:618-624-3838
Mailing Address - Fax:618-624-4478
Practice Address - Street 1:959 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2234
Practice Address - Country:US
Practice Address - Phone:618-624-3838
Practice Address - Fax:618-624-4478
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190247421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208344253OtherTIN