Provider Demographics
NPI:1104040682
Name:BOTTNER, ROBERT ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ANTHONY
Last Name:BOTTNER
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 1:375 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-3521
Mailing Address - Country:US
Mailing Address - Phone:631-581-2038
Mailing Address - Fax:631-224-1322
Practice Address - Street 1:375 MAIN ST
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3521
Practice Address - Country:US
Practice Address - Phone:631-581-2038
Practice Address - Fax:631-224-1322
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04263011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice