Provider Demographics
NPI:1003381914
Name:BOTSFORD, KEYAN (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:KEYAN
Middle Name:
Last Name:BOTSFORD
Suffix:
Gender:F
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 E MCANDREWS RD STE B
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-5334
Mailing Address - Country:US
Mailing Address - Phone:541-779-3003
Mailing Address - Fax:
Practice Address - Street 1:1625 E MCANDREWS RD STE B
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5334
Practice Address - Country:US
Practice Address - Phone:541-779-3003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-06
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD109171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics