Provider Demographics
NPI:1871661801
Name:BOTT, RYAN GEORGE (DDS)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:GEORGE
Last Name:BOTT
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 1:2852 W 4700 S
Mailing Address - Street 2:SUITE A
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84118-2100
Mailing Address - Country:US
Mailing Address - Phone:801-968-9147
Mailing Address - Fax:801-966-2932
Practice Address - Street 1:2852 W 4700 S
Practice Address - Street 2:SUITE A
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84118-2100
Practice Address - Country:US
Practice Address - Phone:801-968-9147
Practice Address - Fax:801-966-2932
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6264440-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice