Provider Demographics
NPI:1477637809
Name:ROTH, STEVEN WILLIAM (DDS)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:WILLIAM
Last Name:ROTH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1701 E THOMAS RD
Mailing Address - Street 2:STE 204
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7675
Mailing Address - Country:US
Mailing Address - Phone:602-253-6600
Mailing Address - Fax:602-733-6480
Practice Address - Street 1:1904 W PARKSIDE LN
Practice Address - Street 2:SUITE 201
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-1228
Practice Address - Country:US
Practice Address - Phone:623-434-9343
Practice Address - Fax:623-321-6268
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ60681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ969470Medicaid