Provider Demographics
NPI:1639365406
Name:BOTIAN, ALEXEY (DDS)
Entity Type:Individual
Prefix:
First Name:ALEXEY
Middle Name:
Last Name:BOTIAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4306 W CRYSTAL LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-4280
Mailing Address - Country:US
Mailing Address - Phone:815-344-0700
Mailing Address - Fax:815-344-2146
Practice Address - Street 1:4306 W CRYSTAL LAKE RD
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4280
Practice Address - Country:US
Practice Address - Phone:815-344-0700
Practice Address - Fax:815-344-2146
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA128861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice