Provider Demographics
NPI:1235230335
Name:ROTH, WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:
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 1:600 WELLWOOD AVE STE D
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2000
Mailing Address - Country:US
Mailing Address - Phone:631-225-1900
Mailing Address - Fax:631-225-1904
Practice Address - Street 1:600 WELLWOOD AVE STE D
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-2000
Practice Address - Country:US
Practice Address - Phone:631-225-1900
Practice Address - Fax:631-225-1904
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030634122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00284859Medicaid