Provider Demographics
NPI:1346502309
Name:KYLE J ROTH IV DDS PA
Entity Type:Organization
Organization Name:KYLE J ROTH IV DDS PA
Other - Org Name:CAROLINA DENTAL ARTS OF CREEDMOOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-345-9511
Mailing Address - Street 1:505 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CREEDMOOR
Mailing Address - State:NC
Mailing Address - Zip Code:27522-8846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CREEDMOOR
Practice Address - State:NC
Practice Address - Zip Code:27522-8846
Practice Address - Country:US
Practice Address - Phone:919-528-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC70261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty