Provider Demographics
NPI:1174685382
Name:BOTROS & NGUYEN DENTAL CORP
Entity Type:Organization
Organization Name:BOTROS & NGUYEN DENTAL CORP
Other - Org Name:CRYSTAL SMILE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMER
Authorized Official - Middle Name:F
Authorized Official - Last Name:BOTROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-754-1888
Mailing Address - Street 1:2502 S BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704
Mailing Address - Country:US
Mailing Address - Phone:714-754-1888
Mailing Address - Fax:714-754-0888
Practice Address - Street 1:2502 S BRISTOL ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704
Practice Address - Country:US
Practice Address - Phone:714-754-1888
Practice Address - Fax:714-754-0888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45093122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9398201Medicaid