=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124257969
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW BOTT D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2009
-----------------------------------------------------
Last Update Date | 07/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1585 SKYLYN DR
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29307-1034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-573-9255
-----------------------------------------------------
Fax | 864-585-8188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1585 SKYLYN DR
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29307-1034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-573-9255
-----------------------------------------------------
Fax | 864-585-8188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 4627
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------