Provider Demographics
NPI:1124156476
Name:DONALD P. ROTEN, DDS, P.A.
Entity type:Organization
Organization Name:DONALD P. ROTEN, DDS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:PERRIN
Authorized Official - Last Name:ROTEN
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:662-837-4664
Mailing Address - Street 1:307 UNION ST
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-1718
Mailing Address - Country:US
Mailing Address - Phone:662-837-4664
Mailing Address - Fax:662-837-1501
Practice Address - Street 1:307 UNION ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-1718
Practice Address - Country:US
Practice Address - Phone:662-837-4664
Practice Address - Fax:662-837-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS1279-67261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060081Medicaid