Provider Demographics
NPI:1114262987
Name:BOTROUS, MATTA JOSEPH MATTA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTA
Middle Name:JOSEPH MATTA
Last Name:BOTROUS
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 1:35894 ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-7409
Mailing Address - Country:US
Mailing Address - Phone:714-650-1661
Mailing Address - Fax:
Practice Address - Street 1:35894 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-7409
Practice Address - Country:US
Practice Address - Phone:714-650-1661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2016-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62073122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist