Healthcare Provider Details

I. General information

NPI: 1760740518
Provider Name (Legal Business Name): ANTONIO BERTO BOTELLA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 COIT RD
PLANO TX
75023-5942
US

IV. Provider business mailing address

6934 MIDBURY DR
DALLAS TX
75230-3130
US

V. Phone/Fax

Practice location:
  • Phone: 972-596-9400
  • Fax:
Mailing address:
  • Phone: 214-457-9281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number25376
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: