Provider Demographics
NPI:1235153081
Name:ROTH, KATHLEEN (DDS)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
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:262-334-1230
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1354122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist