Provider Demographics
NPI:1417041005
Name:BOTSFORD, KENT T III
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:T
Last Name:BOTSFORD
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 EAST DIVISON STREET
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935
Mailing Address - Country:US
Mailing Address - Phone:920-921-2860
Mailing Address - Fax:920-921-4228
Practice Address - Street 1:525 EAST DIVISION STREET
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935
Practice Address - Country:US
Practice Address - Phone:920-921-2860
Practice Address - Fax:920-921-4228
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1223G0001X1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice