Individual
DR. BRUCE E ROTTER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.M.D.
Contact information
Practice address
132 CRYSTAL GATE LN, GLEN CARBON, IL 62034-1141
(618) 288-0962
Mailing address
132 CRYSTAL GATE LN, GLEN CARBON, IL 62034-1141
(618) 288-0962
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
019-018159
IL
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
021-001642
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1420102
UNITED CONCORDIA PROV ID
IL
01
—
480442
HEALTHLINK INS PROV ID
IL
Enumeration date
10/04/2005
Last updated
04/17/2013
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