Provider Demographics
NPI:1356325906
Name:ROETTGER, MARK ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:ROETTGER
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 1:12425 55TH STREET N
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-4450
Mailing Address - Country:US
Mailing Address - Phone:651-439-0322
Mailing Address - Fax:651-439-2201
Practice Address - Street 1:12425 55TH STREET N
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-4450
Practice Address - Country:US
Practice Address - Phone:651-439-0322
Practice Address - Fax:651-439-2201
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9426122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist