Provider Demographics
NPI:1205863099
Name:ROTH, DANIEL H (DDS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:H
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 1:509 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-3853
Mailing Address - Country:US
Mailing Address - Phone:262-334-5249
Mailing Address - Fax:
Practice Address - Street 1:1713 VOGT DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-8516
Practice Address - Country:US
Practice Address - Phone:262-334-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13431223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics