Provider Demographics
NPI:1437221868
Name:BOTNEN, HEATHER REBECCA (RDH)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:REBECCA
Last Name:BOTNEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ALBATROSS AVE APT A
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6810
Mailing Address - Country:US
Mailing Address - Phone:907-487-2309
Mailing Address - Fax:
Practice Address - Street 1:BLDG N46 US COAST GUARD BASE
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615
Practice Address - Country:US
Practice Address - Phone:907-487-5757
Practice Address - Fax:907-487-5360
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1010124Q00000X
AK579124Q00000X
ORH4372124Q00000X
WADH00005124124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist