Provider Demographics
NPI:1568682060
Name:ROTH, CHARLES D (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
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 1:5775 MAIN STREET
Mailing Address - Street 2:P.O. BOX 703
Mailing Address - City:ROCK HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21661
Mailing Address - Country:US
Mailing Address - Phone:410-778-1234
Mailing Address - Fax:410-778-0232
Practice Address - Street 1:5775 MAIN STREET
Practice Address - Street 2:
Practice Address - City:ROCK HALL
Practice Address - State:MD
Practice Address - Zip Code:21661
Practice Address - Country:US
Practice Address - Phone:410-778-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD9769122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD9769OtherMD STATE DENTAL LICENSE #