Provider Demographics
NPI:1609553759
Name:RESERVOIR DENTAL LLC
Entity Type:Organization
Organization Name:RESERVOIR DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VLAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTEZATU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-400-8868
Mailing Address - Street 1:725 RESERVOIR AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-4452
Mailing Address - Country:US
Mailing Address - Phone:401-400-8868
Mailing Address - Fax:401-406-2710
Practice Address - Street 1:725 RESERVOIR AVE STE 304
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-4452
Practice Address - Country:US
Practice Address - Phone:401-400-8868
Practice Address - Fax:401-406-2710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty