Provider Demographics
NPI:1548212905
Name:ROTH, DONALD J (DDS)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:J
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 1:1000 NEWBURY RD
Mailing Address - Street 2:SUITE 245
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-3613
Mailing Address - Country:US
Mailing Address - Phone:805-499-3130
Mailing Address - Fax:
Practice Address - Street 1:1000 NEWBURY RD
Practice Address - Street 2:SUITE 245
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91320-3613
Practice Address - Country:US
Practice Address - Phone:805-499-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41531122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist