Healthcare Provider Details

I. General information

NPI: 1174441224
Provider Name (Legal Business Name): SAREL JOHANNES PHILUPPUS BOTHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W LINCOLN HWY
EXTON PA
19341-2609
US

IV. Provider business mailing address

1108 PETRICK LN
CHALFONT PA
18914-1071
US

V. Phone/Fax

Practice location:
  • Phone: 215-534-2859
  • Fax:
Mailing address:
  • Phone: 215-534-2859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.028486
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN124164
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS045672
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: