Provider Demographics
NPI:1801337985
Name:BOTTEN, CARLY (DENTAL HYGIENIST)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:BOTTEN
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15910 W COMPANY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-5320
Mailing Address - Country:US
Mailing Address - Phone:715-634-2541
Mailing Address - Fax:
Practice Address - Street 1:15910 W COMPANY LAKE RD
Practice Address - Street 2:C/O TRICIA KRYM
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-5320
Practice Address - Country:US
Practice Address - Phone:715-634-2541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1003022124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist