Provider Demographics
NPI:1356072268
Name:ROTH, LINDSAY
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2053 MISSION DR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-7108
Mailing Address - Country:US
Mailing Address - Phone:239-595-5578
Mailing Address - Fax:
Practice Address - Street 1:6871 DANIELS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-1510
Practice Address - Country:US
Practice Address - Phone:239-288-0537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN27103122300000X
FL27103122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist