Provider Demographics
NPI:1083232441
Name:BOTTROS, KEYROLOS (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEYROLOS
Middle Name:
Last Name:BOTTROS
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 1:421 N KELLY CT
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-5304
Mailing Address - Country:US
Mailing Address - Phone:402-238-7959
Mailing Address - Fax:
Practice Address - Street 1:421 N KELLY CT
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-5304
Practice Address - Country:US
Practice Address - Phone:402-238-7959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032787122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist