Provider Demographics
NPI:1588002596
Name:BOTT, JONATHAN DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DAVID
Last Name:BOTT
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 1:129 LEGENDS WAY
Mailing Address - Street 2:#356
Mailing Address - City:WALTON
Mailing Address - State:KY
Mailing Address - Zip Code:41094
Mailing Address - Country:US
Mailing Address - Phone:859-333-7830
Mailing Address - Fax:
Practice Address - Street 1:7901 MALL RD
Practice Address - Street 2:SUITE 500
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1496
Practice Address - Country:US
Practice Address - Phone:859-647-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9324122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist