Provider Demographics
NPI:1356403570
Name:BOTELER, WILLIAM L (DDS, PA)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:L
Last Name:BOTELER
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5935 HIGHWAY 18 W
Mailing Address - Street 2:SUITE F
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-9625
Mailing Address - Country:US
Mailing Address - Phone:601-922-7028
Mailing Address - Fax:601-922-9005
Practice Address - Street 1:5935 HIGHWAY 18 W
Practice Address - Street 2:SUITE F
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-9625
Practice Address - Country:US
Practice Address - Phone:601-922-7028
Practice Address - Fax:601-922-9005
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1776-771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice