Provider Demographics
NPI:1609009661
Name:BOTTS, ANNA FEDAK (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:FEDAK
Last Name:BOTTS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53536-1394
Mailing Address - Country:US
Mailing Address - Phone:608-882-4338
Mailing Address - Fax:608-882-6777
Practice Address - Street 1:449 S 1ST ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1394
Practice Address - Country:US
Practice Address - Phone:608-882-4338
Practice Address - Fax:608-882-6777
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64431223G0001X
FL188301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice