Provider Demographics
NPI:1477676062
Name:BOTSHEKAN, HOLLY (DDS)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:
Last Name:BOTSHEKAN
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 1:17037 N 43RD AVE STE A4
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-4026
Mailing Address - Country:US
Mailing Address - Phone:602-896-9688
Mailing Address - Fax:602-896-9633
Practice Address - Street 1:17037 N 43RD AVE SUITE A4
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-4026
Practice Address - Country:US
Practice Address - Phone:602-896-9688
Practice Address - Fax:602-896-9633
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ860909125OtherTAX ID
AZ408527OtherAHCCCS