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General NPI Number Information
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NPI Number | 1174279905
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Entity Type | Individual
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Provider Name | SHAHRAZAD LA MAE BOTELLO RDH, RDHAP
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Gender | Female
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Dates
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Enumeration Date | 03/02/2022
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Last Update Date | 03/02/2022
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Provider Practice Location Address
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Address Line | 31 AREA DENTAL CLINIC EDSON RANGE 310515 PHILLIPS ST.
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City | OCEANSIDE
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State | CA
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Zip | 92058
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Country | US
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Telephone | 760-224-1659
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Fax |
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Provider Business Mailing Address
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Address Line | 1ST DNBN ATTN: CREDENTIALS BOX 555221
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City | CAMP PENDLETON
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State | CA
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Zip | 92055-5221
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Country | US
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Telephone | 760-224-1659
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | HAP803
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | RDH28089
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License Number State | CA
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