Provider Demographics
NPI:1508007717
Name:BOTTS DENTAL SPA PC
Entity Type:Organization
Organization Name:BOTTS DENTAL SPA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:BRYCE
Authorized Official - Last Name:BOTTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-737-2200
Mailing Address - Street 1:1055 N. HOUSTON LEVEE RD.
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-6689
Mailing Address - Country:US
Mailing Address - Phone:901-737-2200
Mailing Address - Fax:901-737-2277
Practice Address - Street 1:1055 N. HOUSTON LEVEE RD.
Practice Address - Street 2:SUITE 102
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-6689
Practice Address - Country:US
Practice Address - Phone:901-737-2200
Practice Address - Fax:901-737-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
TNDS0000008754261QD0000X
BB9917824332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies