Provider Demographics
NPI:1972657872
Name:ROTH, MICHELLE (DC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10279 E HILLERY DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-8907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20831 N SCOTTSDALE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-6489
Practice Address - Country:US
Practice Address - Phone:480-513-8300
Practice Address - Fax:480-513-7678
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5446111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0242730OtherBLUE CROSS BLUE SHIELD
AZAZ0242730OtherBLUE CROSS BLUE SHIELD