Provider Demographics
NPI:1568197614
Name:BOTOROUS, CYRIL (DMD)
Entity Type:Individual
Prefix:DR
First Name:CYRIL
Middle Name:
Last Name:BOTOROUS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 THORNTON ST SE APT 806
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3652
Mailing Address - Country:US
Mailing Address - Phone:612-413-8429
Mailing Address - Fax:
Practice Address - Street 1:606 24TH AVE S STE 200
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1437
Practice Address - Country:US
Practice Address - Phone:612-659-8689
Practice Address - Fax:612-659-8690
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR8381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR838OtherRESIDENT DENTAL LICENCE