Provider Demographics
NPI:1982915716
Name:ROTH, BENJAMIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
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 1:73 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-2276
Mailing Address - Country:US
Mailing Address - Phone:215-901-5959
Mailing Address - Fax:
Practice Address - Street 1:100 WHALON ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-7162
Practice Address - Country:US
Practice Address - Phone:978-345-6911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-26
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18564761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics