Provider Demographics
NPI:1467775122
Name:RICHARD L. BOTZBACH II DENTAL CORPORATION
Entity Type:Organization
Organization Name:RICHARD L. BOTZBACH II DENTAL CORPORATION
Other - Org Name:NELLIE GAIL ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:BOTZBACH
Authorized Official - Suffix:II
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:949-362-9971
Mailing Address - Street 1:6 B LIBERTY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-5835
Mailing Address - Country:US
Mailing Address - Phone:949-362-9971
Mailing Address - Fax:949-362-9886
Practice Address - Street 1:6 B LIBERTY
Practice Address - Street 2:SUITE 220
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-5835
Practice Address - Country:US
Practice Address - Phone:949-362-9971
Practice Address - Fax:949-362-9886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA392351223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty