Provider Demographics
NPI:1700882164
Name:ROTH, ROGER J (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:J
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 1:1801 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3400
Mailing Address - Country:US
Mailing Address - Phone:208-667-1578
Mailing Address - Fax:208-765-9116
Practice Address - Street 1:1801 N 3RD ST
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3400
Practice Address - Country:US
Practice Address - Phone:208-667-1578
Practice Address - Fax:208-765-9116
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDD14431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7170OtherWDS
ID4084OtherBLUE CROSS