Provider Demographics
NPI:1730666595
Name:BOTROS, MINA (DDS)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:BOTROS
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 1:25051 W INTERSTATE 10 APT 6108
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-9018
Mailing Address - Country:US
Mailing Address - Phone:818-930-0584
Mailing Address - Fax:
Practice Address - Street 1:9234 N LOOP 1604 W STE 121
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-2984
Practice Address - Country:US
Practice Address - Phone:210-681-1121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1026741223G0001X
TX391901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice