Provider Demographics
NPI:1679733612
Name:ROTH, BRANDON J (DDS)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:J
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 1:3030 N BALLARD RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8707
Mailing Address - Country:US
Mailing Address - Phone:920-954-8085
Mailing Address - Fax:
Practice Address - Street 1:3030 N BALLARD RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8707
Practice Address - Country:US
Practice Address - Phone:920-954-8085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6253-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist