Provider Demographics
NPI:1104837111
Name:ROTH, KELLY ANN (DDS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:ROTH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7077 PEBBLESTONE AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-6679
Mailing Address - Country:US
Mailing Address - Phone:330-433-9070
Mailing Address - Fax:
Practice Address - Street 1:1515 PORTAGE ST NW
Practice Address - Street 2:SUITE I
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-2290
Practice Address - Country:US
Practice Address - Phone:330-494-0646
Practice Address - Fax:330-494-9181
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice