Provider Demographics
NPI:1841206067
Name:BOTIS, THOMAS GEORGE (DMD, FAGD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:GEORGE
Last Name:BOTIS
Suffix:
Gender:M
Credentials:DMD, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2189 RIVERTON RD
Mailing Address - Street 2:
Mailing Address - City:CINNAMINSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077-3729
Mailing Address - Country:US
Mailing Address - Phone:856-829-5122
Mailing Address - Fax:
Practice Address - Street 1:2189 RIVERTON RD
Practice Address - Street 2:
Practice Address - City:CINNAMINSON
Practice Address - State:NJ
Practice Address - Zip Code:08077-3729
Practice Address - Country:US
Practice Address - Phone:856-829-5122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D1012144001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice