Provider Demographics
NPI:1104065515
Name:ROTH, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 NEW BRITAIN RD
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06037-1318
Mailing Address - Country:US
Mailing Address - Phone:860-505-7278
Mailing Address - Fax:860-505-8145
Practice Address - Street 1:355 NEW BRITAIN RD
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CT
Practice Address - Zip Code:06037-1318
Practice Address - Country:US
Practice Address - Phone:860-324-2767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001773111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor