Provider Demographics
NPI:1740313014
Name:ROTH, MARK JULIAN (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JULIAN
Last Name:ROTH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 CONNECTICUT BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3055
Mailing Address - Country:US
Mailing Address - Phone:860-289-8219
Mailing Address - Fax:860-289-0217
Practice Address - Street 1:53 CONNECTICUT BLVD
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3055
Practice Address - Country:US
Practice Address - Phone:860-289-8219
Practice Address - Fax:860-289-0217
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4847122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist