Provider Demographics
NPI:1134961758
Name:ROTH, ABBY MICHELLE
Entity type:Individual
Prefix:
First Name:ABBY
Middle Name:MICHELLE
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ABBY
Other - Middle Name:MICHELLE
Other - Last Name:POHLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2639 HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-2940
Mailing Address - Country:US
Mailing Address - Phone:217-299-6323
Mailing Address - Fax:
Practice Address - Street 1:21 GLEN ED PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3333
Practice Address - Country:US
Practice Address - Phone:618-656-0608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.035216122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty