Provider Demographics
NPI:1912063025
Name:ROTTMAN, KEITH STEVEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:STEVEN
Last Name:ROTTMAN
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 1:8140 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:LAMBERTVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48144-8673
Mailing Address - Country:US
Mailing Address - Phone:734-854-2685
Mailing Address - Fax:734-854-2687
Practice Address - Street 1:8140 SECOR RD
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:MI
Practice Address - Zip Code:48144-8673
Practice Address - Country:US
Practice Address - Phone:734-854-2685
Practice Address - Fax:734-854-2687
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300178781223S0112X
MI29010135011223S0112X
IL0190188081223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0585102Medicaid
OHRO0850141Medicare ID - Type Unspecified