Provider Demographics
NPI:1295016905
Name:BOTAR, ANDREA J (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:J
Last Name:BOTAR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-1457
Mailing Address - Country:US
Mailing Address - Phone:516-710-8547
Mailing Address - Fax:516-764-3062
Practice Address - Street 1:1575 BROADWAY
Practice Address - Street 2:
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1457
Practice Address - Country:US
Practice Address - Phone:516-710-8547
Practice Address - Fax:516-764-3062
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2015-09-08
Deactivation Date:2011-10-06
Deactivation Code:
Reactivation Date:2012-11-20
Provider Licenses
StateLicense IDTaxonomies
NY043726122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY120730021Medicaid