Provider Demographics
NPI:1639343106
Name:BOTWIN, TODD GLEN (DMD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:GLEN
Last Name:BOTWIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 ROYAL PALM PT
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4253
Mailing Address - Country:US
Mailing Address - Phone:772-257-6101
Mailing Address - Fax:772-257-6102
Practice Address - Street 1:83 ROYAL PALM PT
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4253
Practice Address - Country:US
Practice Address - Phone:772-257-6101
Practice Address - Fax:772-257-6102
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-180181223G0001X
FL18018122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist