Provider Demographics
NPI:1699888354
Name:ROTH, DENNIS D (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:D
Last Name:ROTH
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3639 N SAINT PETERS PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-7303
Mailing Address - Country:US
Mailing Address - Phone:636-441-7500
Mailing Address - Fax:636-441-3004
Practice Address - Street 1:3639 N SAINT PETERS PKWY
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-7303
Practice Address - Country:US
Practice Address - Phone:636-441-7500
Practice Address - Fax:636-441-3004
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORO817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO990101802Medicare PIN