Provider Demographics
NPI:1336354539
Name:JOHN ROTTSCHALK, DMD, PC
Entity Type:Organization
Organization Name:JOHN ROTTSCHALK, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROTTSCHALK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-624-3838
Mailing Address - Street 1:959 LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2234
Mailing Address - Country:US
Mailing Address - Phone:618-624-3838
Mailing Address - Fax:
Practice Address - Street 1:959 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2234
Practice Address - Country:US
Practice Address - Phone:618-624-3838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190247421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty