Provider Demographics
NPI:1639343106
Name:BOTWIN, TODD GLEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:GLEN
Last Name:BOTWIN
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 1:8188 JOG RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33472-2952
Mailing Address - Country:US
Mailing Address - Phone:561-733-0004
Mailing Address - Fax:561-369-2115
Practice Address - Street 1:8188 JOG RD
Practice Address - Street 2:SUITE 104
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33472-2952
Practice Address - Country:US
Practice Address - Phone:561-733-0004
Practice Address - Fax:561-369-2115
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18018122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist