Basic Information
Provider Information | |||||||||
NPI: | 1376683698 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROTH | ||||||||
FirstName: | HEIDI | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SANTOS | ||||||||
OtherFirstName: | HEIDI | ||||||||
OtherMiddleName: | M. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | W8595 BILKIE RD | ||||||||
Address2: |   | ||||||||
City: | POYNETTE | ||||||||
State: | WI | ||||||||
PostalCode: | 539559774 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6086357663 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | S2845 WHITE EAGLE RD | ||||||||
Address2: |   | ||||||||
City: | BARABOO | ||||||||
State: | WI | ||||||||
PostalCode: | 539139064 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083551240 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 4219-016 | WI | Y |   | Dental Providers | Dental Hygienist |   |
No ID Information.