Provider Demographics
NPI:1356417687
Name:BOTTS, JASON BRYCE (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:BRYCE
Last Name:BOTTS
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 1:1055 N HOUSTON LEVEE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-6693
Mailing Address - Country:US
Mailing Address - Phone:901-737-2200
Mailing Address - Fax:901-737-2277
Practice Address - Street 1:1055 N HOUSTON LEVEE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-6693
Practice Address - Country:US
Practice Address - Phone:901-737-2200
Practice Address - Fax:901-737-2277
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3586122300000X
TNDS00000087541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161133608Medicaid