Provider Demographics
NPI:1053383109
Name:ROTH, LAURENCE CHARLES (DDS)
Entity type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:CHARLES
Last Name:ROTH
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 1:2917 BRUCKNER BLVD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-5613
Mailing Address - Country:US
Mailing Address - Phone:718-597-7888
Mailing Address - Fax:718-597-7888
Practice Address - Street 1:2917 BRUCKNER BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5613
Practice Address - Country:US
Practice Address - Phone:718-597-7888
Practice Address - Fax:718-597-7888
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026079DDS122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist