Provider Demographics
NPI:1053481143
Name:BOTANA, MANUEL ALEJANDRO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:ALEJANDRO
Last Name:BOTANA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 WILLOWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-3211
Mailing Address - Country:US
Mailing Address - Phone:585-467-4513
Mailing Address - Fax:585-467-4665
Practice Address - Street 1:295 MONROE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-3660
Practice Address - Country:US
Practice Address - Phone:585-467-4513
Practice Address - Fax:585-467-4665
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0444801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNSDMedicaid